LEARNING DISABILITIES

Contemporary Viewpoints

Edited by

Bryant J. Cratty
Professor Emeritus
University of California at Los Angeles

and

Richard 1. Goldman
Learning Disabilities Consultant
Calabasas Hills, California

Foreword by Drake D. Duane, MD

harwood academic publishers

h. Australia • Canada • China • France • Germany • India • Japan •
a Luxembourg • Malaysia • The Netherlands • Russia • Singapore.
Switzerland • Thailand • United Kingdom
Copyright © 1996 OPA (Overseas Publishers Association) Amsterdam
B.V. Published in The Netherlands by Harwood Academic Publishers.

All rights reserved.

First published 1996

Second printing 1997
7' T
fl

No part of this book may be reproduced or utilized in any form or by any

means, electronic or mechanical, including photocopying and recording,
or by any information storage or retrieval system, without permission in
writing from the publisher. Printed in Canada.

Amsteldijk 166
1st Floor
1079 LH Amsterdam
The Netherlands

British Library Cataloguing in Publication Data

Learning disabilities contemporary viewpoints

1 .Learning disabilities 2.Learning disabled
l.Cratty, Bryant J. ll.Goldman, Richard L.
61 6.8'5889

ISBN 3—7186—0623—2

T7 WT
- 'ANDICAPPD
THE M
,,lSECU
LiA
MGC. No
This book is dedicated to those children with learning
disabilities and their families. Their persistence and
courage on a daily basis in dealing with adversity is a
lesson for all of us. We also admire all those professionals
who devote their lives to the learning disabled and whose
sensitivity, understanding, and awareness help these
youngsters meet their potentiaL
 CONTENTS

Foreword ix
Preface xi
Acknowledgments xiii
List of Contributors xv
Graduation Speech xvii

1 The Role of the Family in Helping the Child or

Adolescent with Learning Disabilities 1

Larry B. Silver

2 Current Trends in Dyslexia Research 27

Franklin R. Manis

3 Understanding and Helping Learning Disabled

Students to Survive and Thrive in Society 43
James Gardner

/4 Social and Emotional Dimensions of Learning Disabilities 61

Steven Forness

5 All Poor Readers Are Not Dyslexic 87

Michael E. Spagna

C Family Dynamics and Learning Disabilities 123

A. Martin Goodman

7 Coordination Problems Among Learning Disabled

Children: Meanings and Implications 141
Bryant I. Cratty

8 Pharmacological Interventions for Children with

Learning and Psychiatric Disorders 1 87
Dennis P. Cantwell
viii Contents

9 The Emotional and Educational Challenges of Dyslexia

and Attention Deficit Disorder: One Story 203
Joan T. Esposito

Resources 213

Index 217
 FOREWORD

No group of neurologicaliy based disorders more urgently calls for an in-

terdisciplinary offensive than learning disabilities. These constitutionally
determined conditions sculpt a child's perception and interaction with his
or her social environment, commonly before formal school years even
commence. Perplexed parents and preschool educators who seek coun-
sel from professionals in pediatrics, speech and language, or occupational
therapy about specific student difficulties are only sometimes provided
with sufficient insight into the behavioral disorder.
During the school years, academic demands upon the unprepared
mind—in an arena fiUed with peers of similar age but varying levels of
cognitive development—further confuse the child, frustrating optimal
achievement. Too often, only after lifelong emotional wounds have been
inflicted, is the nature of the student's struggle correctly identified but still
under-rehabilitated educationaliy, emotionally, and physically. To avert this
failure of an appropriate societal response, the private educational sector
has stepped forward to construct an environment conducive to the aca-
demic and social growth of individual learners, as this text initiated by a
private school confirms. This series of lectures, preserved in print, provides
a permanent resource for the many professionals—teachers, physicians,
psychologists, social workers, speech and language clinicians, and oc-
cupational therapists—who interact with learning disabled students, as
well as for the students themselves and their families.
These chapters have been written by astute clinicians who appreciate
the rigor of clinical research, yet are sensitive to the needs of these stu-
dents. I commend the editors of this book for their foresight in creating the
lecture series, the authors for their perceptiveness, and I recommend their
efforts to a diverse readership as an intellectual resource and inspiration.

Drake D. Duane, MD
Director, Institute for Developmental Behavioral
Neurology/Biological Psychiatry
Professor, Speech and Hearing Sciences, Arizona State University
President, International Academy for Research in Learning Disabilities
Chair, Scientific Advisory Board, National Dyslexia Research Foundation
 PREFACE

This book reflects a commitment by the editors to increase public aware-

ness of learning disabilities. Its primary goals are advancement of the
frontiers of knowledge and dissemination of contemporary information
to parents and professionals. The lectures contained here were given
over a three-year period as part of a seminar series at Landmark West
School in Encino, California.
These lectures present cutting-edge information to parents, teachers,
university students, and other professionals who deal with learning dis-
abled children on a regular basis. Original content has been edited so
that others might profit, as leaders in the field interpret current research
and provide contemporary clinical insights. Presentations as well as
question and answer sessions are included.
Speakers were selected based on reputation and scholarship in the
field. The lectures represent a broad spectrum of expertise from many
disciplines: Drs. Larry Silver and Dennis Cantwell are psychiatrists recog-
nized for their medical observations about the effects of medication on
attention deficit disorders; Steven Forness is a well-known educator who
deals with the various emotional aspects of learning disabilities; Bryant
Cratty, Professor Emeritus, UCLA, summarizes recent research about
poor motor coordination of these children; clinically oriented psycholo-
gists James Gardner and Martin Goodman explore family dynamics and
the effects of school failure. University professors and researchers Frank
Manis and Michael Spagna present a clear picture of current research
and differences in dyslexic children that are currently emerging in the lit-
erature. The professors, psychologists, doctors, and psychiatrists share
their expertise and views on family, educational, and social issues relat-
ing to children with learning disabilities.
The book concludes with a final lecture by Joan Esposito, an adult with
dyslexia and attention deficit disorder, who could barely read until she
was in her forties. Ms. Esposito is past president of the California Learn-
ing Disabilities Association, and executive director and founder of the
Dyslexia Awareness and Resource Center in Santa Barbara, California.
She has turned her personal experience into a crusade, at the state and
national level, by becoming a passionate advocate for dyslexic children
xii Preface

and adults. Through her descriptions, we can all better understand the
frustrations and challenges of having a learning disability.
The editors hope that this book will not only alert readers to current
ideas and trends in the field but, more importantly, create a better under-
standing and awareness of learning disabilities and attention deficit dis-
orders.
 ACKNOWIEDGMENTS

Several individuals provided helpful assistance in the writing of this book,

and we would like to express our thanks. Debra McCowen provided ex-
pert editorial help in obtaining cogent essays from videotaped speeches.
Mark Oechsli assisted in the videotaping of many speakers. Maria Farns-
worth's skills were invaluable during the final drafting of the chapters. In
addition, the editors appreciate the work done by Blessy Briscoe in help-
ing to design the cover of this publication.
 CONTRIBUTORS

Dennis P. Cantwell, MD University of California, Los Angeles, Joseph

Campbell Professor of Child Psychiatry; Director of Residency in Child
Psychiatry

Bryant J. Cratty, EdD University of California, Los Angeles, Professor

Emeritus of Kinesiology

Joan T. Esposito Dyslexia Awareness and Resource Center, Founder and

Executive Director; California Learning Disabilities Association, Past Presi-
dent

Steven Forness, EdD University of California, Los Angeles, Professor of

Psychiatry and Biobehavioral Sciences, School of Medicine; Principal of
In-Patient School, Neuropsychiatric Institute

James Gardner, PhD Clinical Psychologist

A. Martin Goodman, PhD Clinical Psychologist

Franklin R. Manis, PhD University of Southern California, Professor of

Psychology

Larry B. Silver, MD Georgetown University School of Medicine, Clinical

Professor of Psychiatry; Director of Training in Child and Adolescent Psy-
chiatry

Michael E. Spagna, PhD California State University, Northridge, Assistant

Professor of Special Education
The following speech was given by Joanna Sadowsky,
a student graduating from Landmark West School, Encino, California.

GRADUATION SPEECH

This speech is dedicated to anyone who ever has or ever will

experience the difficulties of a learning disability.

It's amazing to me when I remember how I used to be, how I felt and
how things were. How the struggle tugged at my heart making me scared
and vulnerable. How most often I was frustrated and wanted nothing
more than to run forward but my mind had no choice but to walk, a little
slower ... a little slower maybe, a little different but I finally got to the
place I wanted to be.
Landmark West, I thank you for giving me the courage and the willing-
ness to try through so many years of struggle.
To my friends, I thank you. To anyone who has ever shared the joy and
the pain, to anyone who has ever gotten lost within the laughter as well
as the chaos, to those of you who have ever left footprints in my heart
and sweet memories in my head: I will never forget you.
To my family, who let me be exactly what I am, your wisdom taught me
strength and your love taught me compassion; I love you.
Through the years, I have learned more than I could have ever learned
in the classroom. I've learned to never give up on the important things,
the ones that, once accomplished, leave you that feeling in yourself that
you can do anything.
I've gained the power of knowing that no matter what lies ahead of me
is an opportunity for experience.
But most of all, I've learned that overcoming adversity, like a broken
bone, causes you to heal that much stronger.
I walk away from here today a high school graduate taking with me
invaluable lessons; what I leave behind is an insecure 8-year-old who
couldn't read or write and believed she never would. I don't really know
what lies in front of me; but whatever it is and whenever it comes I wel-
come it and look forward to its challenge, secure in the knowledge that I
can do anything!
LECTURE 1

Larry B. Silver, M.D.

Georgetown University School of Medicine
Clinical Professor of Psychiatry
Director of Training in Child and
Adolescent Psychiatry

THE ROLE OF THE

FAMILY IN HELPING
THE CHILD OR
ADOLESCENT WITH
LEARNING DISABILITIES,

'With the understanding and often not-too-gentle persistence

of my teachers I worked through my anger and confusion and
became confident, secure, and even diligent.h*
* Note: This and all subsequent chapter opening quotes are from individuals with
learning disabilities.
2 Larry Silver

Introduction by Richard L. Goldman

I would like to welcome everyone to the first installment of the Landmark
West Speaker Series. Landmark's mission is to educate the dyslexic child
and to help the dyslexic cope with his or her learning disability. In addi-
tion, the school attempts to transcend the daily education of 1 70 students,
through outreach and public awareness. Our Speaker Series helps meet
this goal as experts discuss family, social and educational issues related to
Learning Disabilities.
To inaugurate our series, we are fortunate to have Larry B. Silver, M.D.,
an internationally recognized authority on ADHD and children with
learning and emotional problems. A noted author and lecturer, Dr, Silver
is Clinical Professor of Psychiatry and Director of Training in Child and
Adolescent Psychiatry at Georgetown University School of Medicine.
He has served as Acting Director and Deputy Director of the National
Institute of Mental Health. He is the author of The Misunderstood Child;
Attention Deficit Hyperactivity Disorder: A Clinical Guide to Diagnosis
and Treatment, and, Dr. Larry Silver's Advice to Parents on Attention Defi-
cit Hyperactivity Disorder. Dr. Silver currently is a board member of the
Learning Disabilities Association (LDA) and other associations fQr chil-
dren with learning disabilities and ADHD.
Tonight, Dr. Silver will discuss learning disabilities and attention deficit
disorders as life disorders affecting youngsters through adolescence and
in all aspects of their lives. He will demonstrate how the child can be suc-
cessful within the family and with friends. Without further ado, it is a
great pleasure to introduce Dr. Larry Silver.

Dr. Larry Silver

Tonight, I would like to talk about your roles as parents of a son or daugh-
ter with a learning disability. Your role in helping them is critical if they are
to have the opportunities of becoming successful adults. School is only
part of their lives. If they live in a family that does not understand, or live in
a community that does not understand, their problems are magnified.
Several Landmark students that I talked to today made comments like,
"My problem at home is that my mom knows I have a learning problem,
but my dad doesn't believe it"; or, "One of my parents is still yelling at me
that if! just try harder I would do better. I wish you could help them un-
derstand I'm trying as hard as I can, but I can't do any better than I'm do-
ing." If parents do not understand, there is one more hurdle for the
youngster to overcome.
 The Role of the Family in Helping the Child or Adolescent with ID 3

I would like to take a few minutes to review all the terms I will use. Just
this evening you heard me introduced as talking about dyslexia, learning
disabilities, and ADD. I will take the first few minutes to review an histori-
cal perspective of how we got where we are. From there, we will move to
some of the key issues related to learning disabilities.

HISTORICAL BACKGROUND

In the U.S. prior to 1940, if children had trouble learning, they were put
into one of three major categories: (1) those children who were mentally
retarded; (2) those children who had emotional problems; or (3) those
children who were socially and culturally disadvantaged. By the early
1 940s, we began to recognize that there was a fourth group of children
who were having trouble learning because of the way their nervous sys-
tems functioned. Initially, it was thought that the reason this group of chil-
dren had trouble functioning was because their brains were damaged. Yet,
these children looked normal, so the term applied to this group was Mini-
mal Brain Damage.
Gradually, by the late 1940s and early 1950s, more and more evi-
dence was presented that demonstrated no damage to the brains of
these children. Instead, there existed "difficult" wiring, or faulty neural
functioning. So the name of this disorder was changed to Minimal Brain
Dysfunction.
By the early 1 960s, people were so confused about what "Minimal
Brain Dysfunction" meant that the National Institutes of Health brought
together what was called a "Consensus Conference" to summarize all of
the research and conclude what was meant by this term. The panel con-
cluded that Minimal Brain Dysfunction referred to a group of problems
often found together, where the child had trouble learning because of
the way his or her nervous system operated. Secondly, many children in
this group were hyperactive and/or distractible. Third, many of them had
emotional, social, and family problems.
If we had stopped there, we would have been years ahead of our-
selves, but like most government documents, the "Conference" report
was put on the shelf, collected dust, and was ignored. We had to go
through twenty years of re-inventing the wheel before we discovered the
same conclusions. That is, if we look at the children and adolescents who
go to a school like Landmark, we find a common theme, that they have a
learning disability. We find that about twenty to twenty-five percent of
them also will have Attention Deficit Hyperactive Disorder (a term I'll de-
4 Larry Silver

fine for you later). In addition, many of these children have social, emo-
tional, and family problems.
What causes these secondary emotional, social, and family problems?
Let me give an example. A boy begins school. He gradually falls behind
academically and is kept back. He is now a year older and a head taller
than everyone else in his class. He is still not learning and begins to feel
bad about himself. He becomes totally discouraged and starts to misbe-
have in school. His teacher then calls home telling his parents, "Your
child is not doing this; your child is not doing that." His parents begin to
feel badly and become frustrated, as does the child. It's 100% predict-
able that if there are two parents in the family, one will believe that the
best way to help the child is to be firm and strict, while the other will be-
lieve that the best way to help the child is to be understanding and per-
missive. And so the parents begin to clash with each other. Eventually,
the principal calls the parents in and says, "Your child is not learning due
to emotional problems, obviously due to marital conflict. Co see a mental
health professional." And so these parents go to see a psychiatrist, a so-
cial worker, or a psychologist because their child is misbehaving in
school. Here, everyone is looking at the smoke rather than at the fire. As
such, when we talk about social, emotional, and family problems, it is
critical that we determine whether the social, emotional, or family prob-
lems are causing the academic difficulty or whether the social, emotion-
al, or family problems are consequences of the academic difficulty.
Initially, the terms that were used for these students attempted to label
the presenting issue. If the problem involved reading, the child had dys-
lexia. If the problem involved math and calculations, the child had dyscal-
culia. If the problem involved written language and graphics, the child
had dysgraphia.
Gradually, it became clear that these terms did not have much mean-
ing. Dyslexia does not tell you "why" a child has difficulty reading but
tells you that he or she cannot read. The child may have just moved from
El Salvador and only knows Spanish. Reading problems may occur for
any number of reasons. The experts decided that one had to clarify the
specific learning difficulties that explain why a child has trouble with
reading or writing or with math. The specific learning difficulty term used
today is "Learning Disabilities." As noted earlier, some children are also
hyperactive, distractible, and/or impulsive. Many different terms have
been used for this behavior. The first term used in this country was "Hy-
perkinetic Reaction of Childhood." Today, we call this disorder "Atten-
tion Deficit Hyperactivity Disorder." This disorder is not my topic for
 The Role of the Family in Helping the Child or Adolescent with LD 5

tonight. It is important at this time to realize that "Learning Disability"

and 'Attention Deficit Hyperactivity Disorder" are two separate prob-
lems. The treatment for a learning disability will not cure ADHD. The
treatment for "ADHD" will not treat the learning disability. A parent may
call me and say, 'My child has ADHD, he was put on Rita/in, and he still
can't read very well." The reason is that the reading problem relates to a
learning disability and is not helped with medication.

PARENT HELP

Now let me become more specific with you about what you as parents
can do to help. The first thing we need to understand is that learning dis-
abilities are "life" disabilities. Learning disabilities are not just school prob-
lems. The same learning disabilities that interfere with reading, writing,
and arithmetic interfere with baseball, basketball, four-square, jump rope,
setting the dinner table, getting dressed, keeping a room neat—in short,
with every aspect of life. You may have thought of a learning disability as
"my child can't read, reads backwards or reads upside-down and that's
why he goes to Landmark." But you need to realize that his or her learning
disability also explains why there are so many problems at home or with
peers. Parents must broaden their thinking and realize that their son's or
daughter's brain somehow functions differently, whether he or she is with
family, playing with friends, or at school.
The second thing to keep in mind is that learning disabilities are a "life-
time" disability. The child with a learning disability will become the ado-
lescent with the learning disability, and will become the adult with the
learning disability. Parents don't like to hear this. They want to think that
their child will outgrow it. If they just give the child help for a couple of
years, he or she will get better. I don't say this to make parents fell upset
or depressed. I say it because, if parents face reality, they have a better
chance of dealing with reality. Forty percent of the children with learning
disabilities inherit the disorder from their parents. It runs in families. Par-
ents may have the same problem. They, too, may need help.
The point is that if we get these students the right help, and if we give
them the right skills and strategies for learning, they can do as well as
anyone else. They might need special help through high school. They
might also need to go to a college that can provide help. Today, there are
graduate schools and professional schools all over the country that ac-
commodate to youngsters with learning disabilities.
6 Larry Silver

So, what is your job as a parent? Schools will deal with their academic
needs. Parents need to deal with their psychological, social, family, and
peer needs.

THE NATURE AND SYMPTOMS OF LEARNING DISABILITIES

I want to review what learning disabilities are, focusing on the reality that
learning disabilities are not just a school disability but are a life disability.
This major theme is expounded on in my book, The Misunderstood Child.
This book is written for parents and contains information about what par-
ents can do to help their child to be successful through adolescence.
Often, when I meet with parents who have children who have been in
special education programs for years, they show me a very thick file. I'll
ask them to summarize the information for me. Can they give me a list of
their child's learning disabilities and, equally important, can they give me
a list of their child's abilities and strengths? Most parents cannot. This in-
formation is critical. The job of a parent is to learn how to build on their
child's strength's rather than expose or magnify their weaknesses. The
role of special education programs is to build on the strengths while
helping to compensate for or overcome the weaknesses. To do this, the
parents must know their child's learning abilities as well as the child's dis-
abilities.
It is convenient to break the types of possible learning disabilities
down into simple steps. The model used is a computer-based model.
The first step in learning is to bring information to the brain and record
it. This is called "input." The second step, once the information is in, is to
make sense out of it. This is referred to as "integration." The third step,
after input and integration, is to be able to store information so it can be
retrieved again. This is termed "memory." The last step, after the informa-
tion is brought in, integrated, made sense out of, and stored, is to get the
information out again, called "output." Thus we talk about input disabili-
ties, integration disabilities, memory disabilities, and output disabilities.

INPUT DISABILITIES

Some children have trouble bringing information in using their eyes and
recording it properly. They have "visual input problems." Some children
have trouble bringing information in using their ears and recording it prop-
erly. We call that "auditory input problems." Some children may have a
mixture of both. The teacher is writing on the blackboard, while talking,
 The Role of the Family in Helping the Child or Adolescent with ID 7

and the student can have trouble bringing information in both through the
eyes and ears at the same time and making sense while recording it. The
term we use for this central brain process of seeing or hearing or perceiv-
ing the world is "perception." So the term we use to distinguish this central
brain process of recording something from the outside onto the brain is
"perception." Some children will have a "visual perception problem." Oth-
ers may have an "auditory perception problem."

Visual Perception
Some children or adolescents have difficulty distinguishing differences in
shapes. They may confuse b's and d's and p's and 9's. They may confuse a
ll3 "M", and an "E" where the same symbol can appear in four dif-
ferent positions. They may confuse a "u" and an "n" or a "6" and a "9".
This problem is normal until age six. Another visual perception problem is
"visual figure-ground." This problem refers to difficulty differentiating be-
tween the figure one is to focus on versus the entire visual field, the back-
ground. Some children, when reading, have trouble deciding what words
to look at. As they read, they skip lines, or they read the same line twice.
They must to go back and catch themselves. When they look up from the
page, they trouble deciding where they were when they look down again.
If the table is too cluttered, their eyes look at everything but the important
work on the page. When sitting at the dinner table, they may have difficul-
ty spotting the salt, if asked to pass it. The same child might not hit the nail
with a hammer. Some children have trouble with visual depth perception,
bringing information in through both eyes, fusing it together, and coming
up with three-dimensional vision. These are the children who fall off their
chairs, or who reach for a drink and misjudge it's location, or who, after
cracking an egg, let it hit the table rather than the pot.
How important is visual perception in life? What does it take to catch a
ball, or hit a ball, or throw a ball? The first thing one needs to catch a ball
is "visual figure-ground." One has to look out into the field and spot the
ball from an often confusing background. The second thing one must do
after one spots the ball is to keep one's eyes on it. The reason why
coaches yell at children to keep their eyes on the ball is that if one's eyes
are on the ball, the brain can use depth perception to figure out how fast
the ball is moving so that one can get to the right place and catch it. A
child who skips words and lines when reading may also have a problem
with baseball and basketball. He or she will get their hands up to catch a
ball too soon or too late and get hit in the face. After a while, the child
will just throw up his or her hands to protect the face, because he or she
8 Larry Silver

is afraid of getting hit. These children do not play sports well that require
this kind of eye-hand coordination.

Auditory Perception
A child or adolescent might have difficulty distinguishing subtle differ-
ences in sounds. It is easier to understand the concept of subtle differ-
ences in shapes. There are twenty-six shapes in our alphabet, and ten
shapes in our numerical system. But there are 44 units of sound in the Eng-
lish language, called phonemes. Some words sound very similar, "Blue"
and "blow", "ball" and "bell", "can't" and "can." I might say, "How are
you?" and a child, say eight years old, may appear to be thinking I said,
"How old are you?" This child may not be paying attention because he or
she misunderstands the sounds that are heard.
Some may have an "auditory figure-ground problem:" If there is more
than one sound at any one time, will the child know which one to focus
on?
Let me give an example. John was a ten year-old boy with an auditory
figure-ground problem. I observed him at his home and at his school. At
the home, he was sitting and watching television. His brothers were play-
ing a game on the floor, another sound input. The window was open and
the traffic constituted another sound input. His mother was in the kitch-
en. Suddenly, his mother called out, "john, please come in and set the
table." That brief message lasted about three seconds. John didn't focus
on it. His mother called out three or four times and finally said to me,
"See what I mean. He never pays attention to me!!!" And then John
looked up, totally surprised, with no idea why his mother was angry with
him.
John was surprised because his brain was the only brain he has ever
had. He doesn't know that it is different. He is trying to go through life
like everyone else; but somehow he is always being yelled at for some-
thing, and he does not know why. What John's mother needed to learn
was that her child had an auditory figure-ground problem. If she wanted
to talk to him, she had to make eye contact first. You have to use "visual
figure-ground" to compensate for the "auditory figure-ground disability."
A few days later, I observed John in school. He was sitting at his desk
working. He later described that he had heard noises in his head (think-
ing), noises in the classroom, and noises out in the corridor. The teacher
suddenly said, "Children, it is time to do your math, open your book to
Page 16 and start Problem 4." By the time John realized that the teacher
was talking, he heard "Problem 4." He looked around the room and saw
 The Role of the Family in Helping the Child or Adolescent with LD 9

everyone taking out his or her math books. He took out his math book
and then quietly leaned over the shoulder of the child in front of him to
find out what page Problem 4 was on. At that point, the teacher said,
"John, quit bothering the other children and get to work!!!" You see what
it is like to be John, or Mary, or Allison, or anyone who is constantly being
yelled at? They are accused of being stupid, or lazy, or bad, or dumb,
because they cannot do things as well as everyone else. They look nor-
mal and are expected to be normal. But they are not. It is so important for
parents to know their sons' and daughters' strengths and weaknesses so
that they do not continually frustrate themselves and their children.
Some children will have what is termed an "auditory lag." It takes them
a fraction of a second longer to understand what they have heard. They
are constantly trying to think about what they just heard and miss what
comes next. Sometimes they just can't keep up and miss a piece of in-
formation. They seem not to be paying attention. In the classroom, a
teacher might explain something. Then, the child raises his hand to ask a
question. The teacher says, "I've just explained that. Why don't you lis-
ten?" These are the children who are often called "air heads" or "space
cadets" because they always seem to be misunderstanding what is being
said.

Sensory Integration
There are three other areas of input problems that may not impact on
learning but will impact on life. These three inputs are required to know
where one's body is in space and how to perform motor tasks. The first
input is "tactile perception," or "touch input." There is "light touch" and
"deep touch," or "pressure." You know you are sitting down because you
receive pressure from some parts of your body but not from other parts.
Some children have trouble with "touch input." They may not like to
be held or cuddled. They complain about the tag on the back of their
shirt or say that their belt is too tight. They may not like shoes and socks.
Occupational therapists diagnose and treat this problem.
The second of these inputs is "proprioception." These are the nerve
endings in muscles and joints that tell us which muscle groups are re-
laxed to tight and where each joint is. Some children are confused by
these inputs. They might have difficulty learning to use their muscles in
certain patterns, called "muscle planning." Anything they do that re-
quires a pattern of muscle activity is difficult. They might have a difficulty
buttoning, zippering, and tying.
10 Larry Silver

The third input comes from the inner ear. Our vestibular system tells us
where our head is in space and where we are in relation to the ground.
Balance and movement in space may be difficult if there is a "vestibular
perception difficulty."
So far we have only discussed 25% of the possible learning disabilities,
yet I hope you are beginning to understand that these are "life" disabili-
ties. The same learning disabilities that cause difficulty in school interfere
with sports activities, with home activities like cutting up food and get-
ting dressed. Visual perception skills are needed in jump rope, in hop-
scotch, in four square, as well as in coloring and staying inside the lines
and cutting and staying on the line. All these skills require eye-hand coor-
dination. If everyone at a Boy Scouts meeting or at an Indian Princesses
meeting is drawing a turkey, then cutting it out, the child with the visual
perception problem cannot draw very well or cut very well, and every-
one knows what experiences such children can have. They get teased
and come home and say they don't want to go there anymore.

Integration
Let me ask you to do an exercise to demonstrate the concept of integra-
tion. I want each of you to print on your brain three graphic symbols: a
"d", "o", and a "g". In order to make sense out of this message there are at
least three things a person has to do. The first is to package those symbols
in the correct order, called "sequencing." Were they recorded as "god",
"dog", or "ogd"? The next step is to figure out what each word means,
now that it is packaged correctly, called "extraction." For example, "the
dog" and "you dog" use the same word. In one case, the word refers to an
animal, and in the other case it is an insult. The third task is to put the main
inputs into a concept. This is called "organization."
Integration disabilities refer to sequencing, extraction, and organiza-
tion difficulties. Some children have a visual sequencing or extraction
problem. Others might have an auditory sequencing or extraction prob-
lem.
If a child with a sequencing problem is talking, he or she might start in
the middle and go to the beginning of the thought, then shift to the end.
Eventually, the message comes out so that it can be understood. The seg-
ments do not flow in the right order. This child might explain something
well; but when asked to write it, he or she puts everything down out of
sequence. This child might try to copy something off the board, such as
"21 plus 6", but it comes out "12 pIus 6." He or she transposed the "21"
to a "12." Some have trouble using sequences.
 The Role of the Family in Helping the Child or Adolescent with LD 11

I recently saw a very bright high school student and suspected a learn-
ing disability. I asked him to name the months of the year. He had no
problem naming January through December. I then asked him to tell me
what comes after August. There was a long pause before he said, "Sep-
tember." I asked why the pause, and he said, "I had to start at January
and work my way up." He couldn't use the sequence of months he had
learned. For these children, the dictionary is difficult. They can recite the
alphabet; but when using the dictionary, they have to go back if the next
letter is above and below the last letter. They have to start back at "A"
each time. These are the same children who hit the ball and run to third
base instead of first base. Parents get angry because every time the child
sets the table, he or she cannot remember where the fork goes, or the
knife and spoon. This is the same child who, when younger, put on his or
her pants before his or her underpants. This child might put on a shirt and
then wonder what to do with his or her undershirt. He or she cannot re-
member the sequence of dressing.
"Extraction" difficulties result in trouble picking up the subtle mean-
ings of words. These children do not pick up jokes or understand humor.
They don't laugh when others laugh. Jokes are plays on words, and these
children don't get them. They hear things literally. Idioms or puns have
little meaning to them. I saw a good example of this just a few weeks ago
when I was visiting a school. It was a small special education class with
about ten students. One child started talking, and the teacher said,
"Class, would you please be quiet." Another child said, "I wasn't talking."
The teacher replied, "I know you weren't." This child went on: "But you
said 'class' and therefore you meant me because lam in the class and/am
very angry." Some children appear to be paranoid because they take
what is said literally.
To identify an organizational problem does not require elaborate test-
ing. Just look at their notebook, or locker, or bedroom. One can see their
trouble with organization. Their notebook is a mess, and things are in the
wrong place. They may not bring home what they are supposed to bring
home. Even if they do their homework, they lose it or forget to turn it in.
They seem to always be losing things. Their whole life is disorganized.
They may also have trouble organizing time. If you say that "a book re-
port is due in two weeks," that time is twenty years away to them; and
then the night before, they panic. They cannot plan time. They have
trouble organizing themselves. These behaviors make their friends upset.
Parents may find themselves getting angry when helping with homework
because this child demands so much of the parent's time. If a parent
12 Larry Silver

says, "Go do your homework," it will not get done. If this parents sits
down next to the child and says," What do you have to do tonight, what
do you want to do first? Do you want to do your English first? Great! Get
started, and I'll come back later to check." The homework may get done.
This child needed a parent to help organize and structure the material.

Memory
We think of two kinds of memory: "short.term" and "long-term." "Long-
term" memory refers to material that is stored and can be retrieved when it
is needed. For most children, "long-term" memory is quite good. They may
remember something years old, that others may have forgotten about. If
they go some place once, they know how to get back to it. Some children
may have trouble with "short-term" memory. This is memory that is being
stored and can be retained briefly. One can retain information while fo-
cusing on it; but unless it is reviewed more, the information will not stay.
He or she can call a phone operator and get a number with an area code.
He or she can then keep these ten digits in memory whlle dialing the num-
ber. But, if between getting the number and dialing it, someone starts talk-
ing, this person may forget the number.
Some children with "short-term" memory disabilities have a "visual
short-term memory" disability, while others have an "auditory short-term
memory" disability. Some parents have learned at home that they cannot
give their child more than one instruction at a time. When they say, "1
want you to go upstairs, brush your hair and wash your face, then come
down again," the child will not remember all of the instructions. In a
classroom, the teacher says, "For tonight, your homework is to read
Chapter 6 and answer all the questions at the end of the chapter." This
child goes home and remembers only to read Chapter 6 and does not do
the answers. At school the next day, the child is accused of not doing the
homework. Children with a "short-term memory" disability need repeti-
tion of information to retain it. They sit down at night and memorize a
spelling or vocabulary list, then go to school the next day and forget what
they have learned.
When they sit in class and are shown a math concept, they really un-
derstand it. Yet when they go home that night, they have forgotten how
to do it. But if a parent does the first problem, bringing it back to
memory, the child can do the rest. "Short-term memory" problems inter-
fere in other ways. One may have to read a chapter in a book. He or she
will read the first paragraph and understand t, then the second, then the
 The Role of the Family in Helping the Child or Adolescent with LD 13

third, and fourth, and fifth. When they get to the end of the chapter, they
have no idea what they have read, because they have not retained it.
Some children say "Oh, forget it," or, "It is not important." The reason
might be that they have a "short-term memory" disability. They start to
speak to you. Half-way through, they forget what they are saying. It is
awkward for them to admit, "1 forgot what! was saying." It is easier to say,
"Forget it, it's not important."

Output
There are two ways we get information out of the brain. One way is to use
words or to talk. The other way is to use muscles, as when drawing, gestur-
ing, writing, cutting up paper. We refer to two types of language use:
"spontaneous language" and "demand language." "Spontaneous lan-
guage" refers to self-initiated talking. The child has the luxury of a fraction
of a second in which to organize his or her thoughts, words, and speech.
Some children have no trouble with this. Some children just chatter and
chatter and chatter. "Demand language" refers to situations where the
child must respond without preplanning. What do you think the story is
about?" "What's the answer to Number 6?" "Where is your sister?" The
child must organize his or her thoughts, find the right words, and speak at
the same time. Some children can't do this. The same child may be fluent
and chatter with friends. Yet, when asked a question, he or she delays or
say, "What? Huh?! don't know." He or she can't find the right words. I saw
a young boy the other day and asked him what he liked to do after school.
He said, "I like to go up in my room and play with cards." I replied, "What
do you do with your cards? He said nothing. I then asked, "What kind of
cards? He said, "You know, pictures of sports, you know." He couldn't find
the right words, "baseball cards' and couldn't get them out. But if I held
up a baseball card, and asked him what it was, he would easily respond.
There is nothing wrong with his knowledge. It is just that he cannot re-
trieve words or organize them fast enough. A teacher might say, "This
child is passive aggressive." When asked to clarify, the teacher will re-
spond, "When he wants to, he will speak in class; but when I call on him,
he refuses to answer." This difference may occur because one task in-
volves "spontaneous language" and the other task requires "demand lan-
guage."
The same problem may occur at home. When a child struggles to get
his or her thoughts out with the right words, parents and siblings get frus-
trated with the time needed. Eventually, someone answers for the child.
14 Larry Silver

Motor Output
There are two types of motor output problems: "gross motor" and "fine
motor skills problems." "Gross motor" difficulties refer to coordinating
groups of large muscles: arms, legs, and trunk. Fine motor refers to coordi-
nating teams of small muscles, like the forty-some muscles in your domi-
nant hand when writing.
The child with a "gross motor disability" is clumsy. He or she cannot
run well and might not learn to ride a tricycle or bicycle when everyone
else does. Can you imagine what it feels like to be eight or nine years old
and still need training wheels on your bike?
"Fine motor problems" most commonly impact on writing. This child
holds his or her pen awkwardly and writes slowly. Printing may be pre-
ferred over cursive writing. It is a laborious effort to get anything down
on paper. The child will tell you, "My hand does not work as fast as my
head is thinking." Handwriting is messy. In addition to this mechanical
problem, the child might have a written language disability, manifest in
difficuky getting words down on the page. He or she makes spelling,
grammar, and punctuation errors. The same child who gets A's on spell-
ing tests will misspell the word when writing it. The same child who could
recite every punctuation rule cannot apply them well in writing. This dis-
ability is a problem in the classroom when copying from the blackboard
or taking notes. Homework, of necessity, is usually written work. This
child might resist it, because he or she cannot write fast or easily. Written
language is a problem in daily life as well. How do you write notes to
your friends? If you make spelling errors, your friends might laugh at you.

THE FAMILY

Let's start with chores within the family. How do parents know what
chores to give their son or daughter with learning disabilities? They can
use trial and error. If, however, they know this child's or adolescent's
strengths and weaknesses, they can select chores that build on their
strengths, rather than expose their weaknesses. For a child with "visual
perception" and "visual-motor problems," that is, he or she has difficulty
when his or her eyes must tell the muscles what to do. A parent might not
ask him of her to load or unload the dishwasher (unless the family uses
plastic dishes). This child could, however, walk the dog, bring in the news-
paper, to take out the trash. If the child has a "short-term memory prob-
lem," parents need to write down the chores. "You load the dishwasher
on even number days and unload the dishwasher on odd number days."
 The Role of the Family in Helping the Child or Adolescent with LD 15

If a child or adolescent has a "sequencing problem," a parent might

say, "I know that you have a sequencing problem. So I will draw a typical
place stetting on a piece of paper and put it in the kitchen drawer. When
it is your time to set the table, feel free to take it out and use it to help
you." What is this parent saying? "You have a disability. I would do any-
thing in the world to help you get rid of it. I can't, so I must help you learn
to cope. I cannot excuse you from life. / am going to teach you how to
succeed in life." Parents don't dress the child with a "sequencing prob-
lem." They say, "I know you have problems when dressing, deciding what
to put on first and second. So, I am going to lay your clothes out in the
right order. You start at the end with your Teddy Bear and work your way
down." In this way, the child gains the competence to do things well and
to compensate for problems.
Parents need to know if they must get eye contact before giving
instructions. If the child appears confused, parents need to be able to
know if he or she is just being difficult, or having trouble because of his
or her learning disabilities. Parents cannot do this without knowledge of
this person's learning disabilities.
Do not excuse these children from chores. The other children will get
angry at the double standards. These other children might complain,
"How come I have to make my bed and he doesn't? How come when I do
something, / get in trouble. When she does the same thing, she is ex-
cused?"
What about other activities? I mentioned earlier that children with
"visual perception problems" might have difficulty coloring inside the
lines. What happens in Sunday School, or at Indian Princesses, or at Boy
Scouts? The teacher or instructor may say, "Draw a turkey" or "Cut out a
turkey." For this child, it is really going to be a turkey. The other children
will laugh, and this child will not want to go any more. Suppose the par-
ent worked with the leader, explaining that his or her child had good
gross motor skills and speaks well, but has difficulty with fine motor
tasks. The leader might assign this child the task of explaining the mean-
ing of turkey and how it became the symbol of Thanksgiving. Or the lead-
er might ask this child to hand out the glue and markers or tack up the
pictures the other children have drawn. In this way, this child will be just
as busy and as active as the others but will be doing things with success
rather than failure. He or she will want to return. Remind the leader not
to ask this child to demonstrate knot tying. It might be a disaster. Let him
or her walk carrying the flag. Build on strengths rather than expose weak-
nesses. Create successes rather than failures.
16 Larry Silver

What about camps, day camps, sleep-away camps? Let me use the
same child with "visual perception" and "visual-motor problems." You
know what the "All-American Jock Camp" is like? At the end of the week,
one team feels great, while the other teams feel bad because they did
not win. If this child is sent to this kind of camp, and he or she drops the
ball or plays poorly, it is not hard to predict the outcome with peers. This
child has "good gross motor skills" and can do other other activities well.
Perhaps success will be with soccer, bowling, horseback riding, golf, cer-
tain track and field events, or swimming. Pick a camp that offers these
types of sports. Maybe a waterfront camp with swimming, rowing, ca-
noeing, sailing—all "gross motor" sports.
If a child has "auditory perception problems," the coach needs to be
told that this child may appear to not understand. Ask that the coach re-
view the instructions again. Parents need to run interference. They need
to help find activities at which the child can be successful. Today, at
Landmark, one sixth grade girl said, "1 wish / could talk to my horseback-
riding teacher." I asked why. She responded, "One of the things she is
teaching me is balance, letting go of the reins, putting your hands on your
hips and letting the horse walk. I am always afraid I will fall; but when I
reach over to hold onto the saddle the instructor yells at me to put my
hands back on my hips." Someone need to explain to this riding instruc-
tor why this girl has problems with balance (maybe a "sensory integration
problem"). Let her learn to ride and to have fun with her friends.
If a child has a "demand language disability," he or she may wish to get
into drama. Many might say, "Drama... that is talking, and the child has a
disability in this area." The nice thing about drama class is that once the
child memorizes the script, language is spontaneous. That is why many
"dyslexics" are excellent actresses and actors. You see them on talk
shows, and they may have difficulty putting two thoughts together. How-
ever, give them a script to memorize, and they win Oscars.
As children move toward adolescence, they need to begin to learn to
be their own advocate. They cannot learn self-advocacy during high
school. They will not be able to succeed during their post-high school
years. We often make these children passive. They go to school, and the
special education teacher says, "Sit down and get this work done." They
come home, and the parents say, "Sit down and do your homework." Tu-
tors often give work without explaining why. We need to help them un-
derstand themselves. In early adolescence, we have to teach them to be
their own advocates. They have to know their nervous systems and their
limitations and strengths and so do the parents and the professionals
 The Role of the Family in Helping the Child or Adolescent with LD 17

working with them. They may need help in talking to their friends or ex-
plaining themselves to their friends. For example, let's think of a high
school student who is still reading at the third grade level and who is go-
ing to a place like Landmark. He or she may go out with friends and be
handed a movie guide. Someone asks, "What movie do you want to see
tonight?" Or, he or she is given a TV guide and asked, "What do you want
to watch?" Reading is a problem every place he or she goes. At a restau-
rant, he or she cannot read the menu. These students need to know
when and what to tell friends. Some of the students I met with today said
that they were afraid to tell friends because "they will think that I am stu-
pid and they will not like me anymore." One child said, "I tellmy friends
that I go to a private school in Encino. I do not tell them it is a Landmark
West because they will think I am going to a retard school." That is how
she feels about herself. We need to help students know that they are not
stupid, that they are not dumb, that they are not bad, and that they are
not lazy. We need to help them understand that some parts of their ner-
vous systems are wired a little differently and, as a result, that they may
need to learn differently.
We need to help them learn to be their own advocates. For example,
we need to help them learn how to explain to a friend that they read
slowly, or how to explain that sometimes they get lost in space, or don't
know their left from their right. Parents or other adults have to role play
to teach them how to explain to someone that they have a "learning dis-
ability" and how it interferes with their life. Parents need to be supportive
when these children are working with their friends and teachers and
must teach them how to fight their battles.
Let them give you an example: One mother approached the new
teacher the day before school started and told her, "My son has been
mainstreamed, he has dyslexia. He doesn't read very fast, and! wouldap-
preciate it if you give him untimed tests." If this happens, you can predict
what is going to occur. First, the teacher is going to say, "Look, Lady, I
have twenty-five to thirty children in my class, five periods each day. I
can't do things like that." Or, "Look, the child is growing up. You have to
get off the child's back and let him do things." A parent taking this kind of
demanding attitude wouldn't get much cooperation. But let me tell you
how we taught a child to work with his teacher. He met with theteacher
himself and said, "1 want you to know that I personally picked you to be
my English teacher during the 11th grade." Don't ask your child to do this
to impress the teacher. The child should know whether he or she can do
better with a teacher who does a lot of lecturing, because auditory per-
18 Larry Silver

ception is a strength. Or will he or she do better with teachers who are

lazy and just give out worksheets? If a child does better visually, he or she
might do better with a teacher who is organized than with a teacher who
is disorganized. However, the disorganized teacher may be best for
some children because he or she does not teach well and does not lec-
ture rapidly. This child can take reasonable notes from this kind of teach-
er. What parents should say to this student is, When you are finishing the
11th grade, talk to your friends about the teachers in 1 2th grade and se-
lect the teachers who best meet your needs.
The second thing this particular boy said to the teacher was, "I know
we have a lot of reading. I don't read fast, but! got the reading list in April,
and I have started over the summer. / have finished reading several books.
One of them is difficult, but! have arranged too have it on tape. So, I will
be in good shape." What he is saying to the teacher is, "I have a disability,
I know it will take a lot of effort on my part to do well, but I am willing to
put in that effort. I am now asking you to excuse me." It is true that a child
with a learning disability has to learn differently. It is also true that the
effort will take much more of his or her time. The child needs to know
and accept this fact if he or she wants to be successful. The child will
have to work twice as hard. He or she may have to spend twice as much
time on homework.
The boy went on to say, "When I read out loud I sometimes mess up
words and stumble on words. I feel kind of foolish. Would you please nev-
er call on me in class to read out loud, because I will not do very well."
The last thing he said was, "I have a lot of good thoughts in my head, and
when I talk about them, I do great, but when I try to put them on paper, it
somehow just does not come out too well. So, could I please take un-
timed tests, if! need to I will come in early before class and work after
class, and I promise not to cheat."
First, it would be an awfully hard-headed teacher who would tell this
child, "No." Secondly, understand the level of understanding this student
has about himself. This is our goal. Self-knowledge leads to self-advoca-
cy.
Another example: A boy wanted to get his driver's license. His learn-
ing disabilities were "auditory perception" and "auditory short-term
memory." He had no trouble with the written test. However, he did have
trouble with the driver's test. He slipped behind the wheel. The examin-
er, a man who must do the same thing every day for years, said, "Okay,
pull out and go to the nearest stop sign. Make a left, and then wait for the
next set of instructions."
 The Role of the Family in Helping the Child or Adolescent with ID 19

The boy blew it.

I met with the family and discussed what to do. Dad said, "Why don't
you send a letter to the Department of Motor Vehicles andsay that he has
a learning disability?" The boy immediately rejected the idea because no
teenager wants to be different. After going through many possibilities,
the father and son reached a solution. They went to the test site, where
the boy interviewed people after they had taken the test. The examiner
used a standard driving test, and so it was not long before the boy had
the procedure written down and memorized. So when he went back the
second time, it made no difference what language the examiner was
speaking. The boy knew what was going to happen. He passed the test
using his strategies and compensations, It is important to teach adoles-
cents to fight their own battles rather than doing it for them.
Helping
them learn how to learn and how to explain their abilities to friends is
important.

SUMMARY

What am I trying to say? Each of you are here because your son or daugh-
ter has a learning disability. Some of you might say, "No, my son or daugh-
ter just needs a small school or private classes and just a little extra
attention."
Please, erase the denial. If you don't believe it, they won't believe it.
Your child or adolescent is here because he or she has a learning disabil-
ity. What is important is that he or she is bright andcan learn. It is impor-
tant for you as parents to learn your child's profile oflearning disabilities
and learning abilities, If you don't know this, there is no way you can cre-
atively or correctly help them. You have to teach your child his or her
abilities and disabilities. Otherwise, he or she will go through life playing
a trial and error game. You need to know how to apply this knowledge in
order to build on strengths rather than to expose weaknesses. As they
get older, you need to teach them to do their own advocacy.

QUESTIONS AND ANSWERS

Question: What about family problems and their psychological ef-

fects?
Dr. Silver: These children obviously have social and emotional prob-
lems. Professionals should move in and work with them. The key here is
for the professional to understand the abilities and disabilities of the child
20 Larry Silver

as well as the parent does. It is frustrating to be in therapy with someone

who does not understand the relationship between emotional problems
and learning disabilities, who does not understand learning disabilities.
Also, if the child is with a therapist who does a lot of talking, and if they
have auditory problems, and the therapist does not know it, the therapist
is going to get frustrated and accuse the child of not paying attention.
Question: My child has a short-term memory problem and cannot
seem to memorize what is in a book but memorize baseball cards very
well. Why is this?
Dr. Silver: Motivation is part of the factor. That is where the school
come in and helps. Another thing is that some types of memory work is
non-threatening, especially if it is learned at their pace, like baseball sta-
tistics. But when memorizing a spelling test, your child is taking a big risk.
Many of these children do quite well in non-threatening or safe areas.
Question: My daughter doesn't want anyone to know she has a learn-
ing problem. She feels that she is stupid and that something is wrong
with her.
Dr. Silver: Today at school, we discussed with your youngsters the dif-
ference between being dumb and being stupid. Being dumb, I told them,
means that your IQ is below average. I reassured these children that they
would not be here at Landmark if that were true. On the other hand, be-
ing stupid, I told them, means that you can't do what everyone else can
do. Some children will tell me, "If I'm so smart, how come I'm so stupid?"
If they cannot read as well as the other children, if they cannot do math
as well, if they cannot write as well, they feel stupid. That is a very subjec-
tive feeling. I can't help them to get rid of that poor self-image until they
start succeeding. Only then do they start to feel better about themselves.
So you have to acknowledge the difference between the two words.
Many of these children have learned the hard way that people do not
understand them and their disability. They learned that in a regular
school, going to the resource room got them teased because they had to
go to the "retard room." They learned that they have to cover up orhide
their special treatment.
All children between the ages of thirteen and fifteen can't tolerate be-
ing different. This is an age period that is horrible anyway. At this age,
they don't like to be different, they don't like anyone else being different.
They have their own little cliques, their own little groups, and their own
little in-groups at this age. This is an age period in which many have tre-
mendous difficulties. Learning disabled children learn from experience
that they get laughed at or teased if they tell people that they have a
 The Role of the Family in Helping the Child or Adolescent with LD 21

problem. This is an age period in which it is painful to be different. So

what I think you can do about your daughter is to try to be supportive
and understanding. Ask the staff here to help you. If it gets to be a real
problem, you should seek some expert help to see what you can do
about it. Many of the children today were telling me how much energy
they put into covering up their problems. They don't want people to
know what their problems are. It is hard to explain their difficulties, plus
people begin to think that they are dumb.
If you can't listen and talk very well, people assume that you are an
"air-head" or a "space cadet". When these children struggle with the real
world, it is usually easier to cover up and not be honest when dealing
with the problem. Some parents have had the experience with neighbors
who upon hearing that the child is in a special education class tell their
children to stop playing with the child because their is something wrong
with him of her. Some of you may not have had that experience; but your
children have certainly had that happen to them. So I think we have to be
supportive. We have to be understanding. We have to help them to find
ways of feeling better about themselves. Sometimes in high school, it be-
comes easier because it is easier to be honest with the best friends
youngsters make there. So we must also buy some time.
Question: Is there a standard form of discipline that works best?
Dr. Silver: No. The key is for both parents, if there are two parents, to
agree with a single approach and to be consistent when imposing it.
What I tell parents is that in addition to being children, they also have a
learning disability. Thus, you also have to form parental boundaries as to
what is acceptable or unacceptable behavior in the family. Try to agree
upon what is acceptable behavior. Difficulties arise when the child blows
up during his first minutes home from school. He or she has held in the
anger and frustration all day, and then let it out at home, where it is safe.
He or she may get angry with a brother or sister who may be two years
younger but who has no problems and may be breezing through school
with straight A's with no effort. Thus, consistency helps, and structure is
helpful. If you really can't figure out what to do, you might sit down with
some of the people here at Landmark and figure out what to do. If the
behavior is totally unacceptable, one of the chapters in my book de-
scribes a point system and time-out system that work with some of the
children. After you get unwanted behaviors under control in these ways,
you can move to more casual forms of discipline.
Question: What about the frustrations parents have when helping chil-
dren with their homework?
22 Larry Silver

Dr. Silver: The rule of thumb is, if homework becomes a battle zone,
them pull out and let the school deal with it. If youngsters refuse to do
their homework, then the school- will easily find out the next day when
the child returns without the homework done. If you've gotten beyond
that, and the child is really trying hard, then you say, "The homework is
up to you. If you want any help, then I'll be glad to help you. But if you get
frustrated, and your help is just not working, then what you might say is,
"1 really apologize, I really thought I understood your learning problems,
but clearly I don't understand well enough to teach you.1 Why don't you
just skip it tonight, and I'll call your teacher tomorrow and ask him how I
can help you." Then, you get someone at the school to show you that
your child will learn faster if you use methods A, B, or C. Since parents
don't have backgrounds in special education, send a signal to the young-
ster that lets him or her know that you do not know how to help and that
is your problem, that you will figure it out together with the help of the
teacher. But again: if homework time becomes a battle zone, pull away,
and let the school give advice and directions as how to best interact with
your child during homework time.
Question: It is true that these children do not get rid of their problems?
Isn't there some exercise or program or something that helps them get
rid of their problems?
Dr. Silver: How many of you as adults have learning disabilities?
(Hands raised). How many of you have gotten rid of them? (Laughter.) I
don't say this to make you feel badly, I say this to be realistic. We do not
know yet how to get rid of learning disabilities. An awful lot of people are
making millions of dollars promising patients magic cures with brain
studies and vibrating beds and such. These "cures" do not work. What
does work is if we can teach your sons or daughters how to use their
strengths and how to compensate for their weaknesses. If we can teach
them strategies for learning, then they can be successful people.
My reading skills are still quite low. I was able to read a good book on
the plane on the way out here because I had it on tape. My spelling is
very poor, and my writing is still very slow and tedious. I use a word pro-
cessor if I am to do any writing. But my listening and talking skills are
quite good, so I have ended up in a field like psychiatry, versus surgery.
Likewise, these children will learn how to build on their strengths and
compensate for their weaknesses. Some learning disabilities can be com-
pensated for, after which they no longer present major difficulties. Most
of the problems, however, will remain to be dealt with in some way.
 The Role of the Family in Helping the Child or Adolescent with ID 23

Question: What about social problems my child has with teachers and
with other students?
Dr. Silver: One of the social problems children with learning disabili-
ties have is that they do not read social cues. We don't know if that is a
perceptual problem. They do not read that look on your face, or your
body language correctly that says, "Hey, you are going too far, you are
annoying me and other people." Most children by the age of two, when
they are playing outside, know by your tone of voice that they had better
come in this time when you call, or they will get into trouble. Most chil-
dren by the age of three know by your body language when you come
home from work that they can be a pest, or that they should leave you
alone. Children with learning disabilities don't know the meaning of
these cues. They just blunder into social errors. We can teach them how
to read social cues. We teach it through social skills training, and we
teach it much as we do reading. We break reading down into steps, and
then we put it back together again. We do the same thing when teaching
social skills and the interpretation of social cues.
I am teaching social skills to some nine year-olds now. Last week, we
worked on how you ask someone what time it is. This sounds very ob-
vious. However, when you are on the phone, and the child is asking you
what time it is, he or she is exhibiting this problem. In the training session,
we broke "asking for the time" down into steps. Step number one was,
"How do you know who may be able to tell you?" (You look to see if they
have a watch on their wrist.) Step number two was, "You walk up to
them." Step number three was, "You say, 'Excuse me." Step number four
was to ask, "Can you tell me what time it is?" Step number five was to say,
"Thank you." As the children role-played those skills, they began to un-
derstand. You have to teach these skills. Sometimes you have to teach
them through exercise intended to help them find out what different
kinds of facial expressions mean, what various kinds of voices mean, and
why some people get irritated when you do not read their non-verbal
cues accurately.
Question: Could you talk about diagnosis. I have a child who is a bor-
derline LD child. But it is clear that the teachers feel she has definite prob-
lems, and this is impacting upon our family.
Dr. Silver: I will stick with learning disabilities as a generic term, rather
than dyslexia, which is one aspect of learning disabilities. There is a dif-
ference between having a learning disability and being eligible for ser-
vices. Having a learning disability means that there is evidence that your
child is learning differently in certain areas. The way you sort that out is to
24 Larry Silver

use one or more of three sets of tests. The first test is an intellectual as-
sessment. This doesn't have to be an lQ test, but you need to know what
your son's or daughter's intellectual potential is and whether they are
overachieving or underachieving. Also, you should look at various mea-
sures of intelligence and look for any consistencies. Scores I saw yester-
day included a verbal score of 1 48 and a performance score of 96, a
tremendous difference. The second test involves some sort of achieve-
ment test. The achievement test gives a feeling for the discrepancies be-
tween performance and potentials. If there is enough of a discrepancy, a
third set of test may be used that specifically recognize and diagnose
learning disabilities. The most popular test is the Woodcock-Johnson,
but there are many others around.
These three sets of tests, a psycho-educational battery, will give you a
diagnosis. The school system will go one step further. Under Federal law,
there are discrepancy formulas that tell if the child falls far enough be-
hind to qualify for services. Depending on the budget and how many
children they are trying to service, the school district may change the
equation to decrease numbers coming into the system or to increase
children coming out of the system. School district personnel might sit
down with you and say, "Yes, I agree that your child has a learning dis-
ability, and I agree with all these scores; but he or she is not two years
behind in a skill area. Therefore, he or she is not eligible for services. Or,
they may agree with you that your child has an IQ of 1 40, so getting aver-
age grades is underachieving of failing. However, they may not pay atten-
tion to the fact that you are doing two to three hours of homework per
night with your child. What you are doing is teaching your youngster and
doing the work for him or her. The only way for your child to be eligible
for services is for you to stop helping, to pull the rug out from under him
or her, and to permit your child to fail. Then, school personnel will say,
"Yes," and extend help by permitting him or her to obtain services for
learning disabled children. You may decide not to do this, as it would not
be fair to your child.
The definition of a learning disability is reasonably clear, the tests
needed to make the diagnosis are reasonably clear, but school systems
will use different scores and formulas and will debate with you when de-
ciding whether or not your child needs and wiH receive services. To ex-
pand that answer and to make it specific to your child, you will need to sit
down with some staff here at Landmark and go over the issues.
Question: My child startles easily, and I want to know whether this is
indicative of my problem.
 The Role of the Family in Helping the Child or Adolescent with ID 25

Dr. Silver: How old is she?

Parent: Fifteen; but she has always been that way.
Dr. Silver: In general, if something is going to impact upon the nervous
system (in the form of trauma, head injuries due to auto or motorcycle
accidents, trauma during delivery or brain surgery), usually problems de-
velop that reflect the specific area of the brain that is affected. If your
child's nervous system is impacted upon during pregnancy, then any are
of the brain that is developing at that point is vulnerable. That is why
many of your children have multiple sets of problems. Learning disabili-
ties may thus be accompanied by hyperactivity, Tourette's Syndrome, or
seizure disorders. Learning disabled children often have clusters of prob-
lems. A pronounced startle reflex usually means that a primitive reflex is
lasting longer than would normally be expected. Another example that
you may have seen when your children were young was that they had
problems with a stretch reflex. Most children get rid of this problem early
in life. The stretch reflex is elicited by pressing on a muscle so that it will
retract. When you press on the hand, for example, the hand will grasp. In
some of your children, this type of response may have lasted longer, and
so what you may have discovered is when you put the child on your arm
to feed and put pressure on the back muscles, the child backed off and
extends away from you. You began to think that the child didn't like you.
There is something called the tonic-neck reflex that every child has and
that goes away during the first weeks of life. That may have lasted longer
in your children. The tonic-neck reflex means that when you turn your
head, the arm toward which you are turning goes up over the head.
Some mothers tell me that when they try to feed the child and turn the
child's head toward the nipple, the child pushes the mother away. This
action is only a sign that the tonic-neck reflex is lasting longer than it
should. So that is one possibility.
The other possibility is that if they have auditory distractibility, re-
flected in difficulties blocking out sounds in their environment, then loud
noises or sounds become very scary to them. They hate circuses, noisy
birthday parties, fire drill alarms. Sudden noises can lead to startle reac-
tions. There are many possible reasons for an unusual startle response. If
the response continues until the age of fifteen, you should really try to
help the adolescent cope with it.
Question: I have two children with learning disabilities and one teen-
ager with none. Recently, one child without problems has become very
critical of and cruel with the two other children, calling them names.
What can I do?
26 Larry Silver

Dr. Silver: Part of the problem with being fifteen is that one does not
like people to be different. The other problem is that one does not under-
stand the concept of "empathy"; one doesn't know how other people
feel. You have to make an effort to have him or her stop the abusive be-
havior and to understand that other people's feelings are hurt by the
abuse. However, if this advice fails, at some point you may have to say,
"No more. Every time I hear you verbally abusing your brother or sister,
you will spend three hours in your room. I am tired of explaining and be-
ing reasonable. I can't allow you to hinder your brother or sister's posi-
tive growth and development, so you must stop abusing and teasing
them or suffer the penalties I have outlined."
LECTURE 2

Franklin R. Manis, Ph.D.

University of Southern California
Professor of Psychology

CURRENT TRENDS IN
DYSLEXIA RESEARCH

"Anyone can pursue their goals with hard work and dedication,
no matter what hurdles stand in the way.'
28 Frank Manis

Introduction by Richard L. Goldman

Tonight's lecturer is oriented toward understanding dylexia. Our speaker
is an Associate Professor of Psychology at the University of Southern
California (USC). He specializes in research on learning disabilities in cog-
nitive development. Dr. Manis has been conducting research studies at
Landmark West for seven years, focusing on subtypes of dyslexia, reading
problems as well as genetic issues related to the disability.
Dr. Manis will summarize the recent research in the field and its im-
plications for parents and professionals. I am pleased to present Dr.
Frank Manis.

Dr. Franklin Manis:

I first became interested in learning disabilities during graduate school. A
visiting faculty member mentioned to me that he was starting a study with
reading disabilities and I was intrigued. We began by tutoring children in a
program in the Bloomington, Minnesota School District created by Mary
Lee Enfield which involved a structured phonics approach to reading re-
mediation. At that point I was struck by the paradox of the person who has
excellent or average language comprehension, yet who, when coming to
the printed page, has such difficulties. This was a scientific puzzle to me. I
have spent my professional research career studying and investigating the
cognitive bases for such learning disorders.
I have two general goals this evening. First, I want to summarize some
of the recent research on the biological and cognitive bases of dyslexia.
Secondly, I would like to discuss in some depth unanswered questions
that I think researchers should themselves be answering. As I summarize
the current research on dyslexia, keep in mind that these are only brief
sketches. If you would like me to elaborate on any of the points I make,
please save your questions for later.
The most basic question is: what is the origin of dyslexia? Recently it
has become clear that at least some cases of dyslexia have a genetic ba-
sis. Work by Pennington, Smith and others at the University of Colorado
seems to indicate that at least one form of dyslexia originates in a single
gene located on chromosome 1 5. Their findings indicate that less than
20% of families may have the single gene form of dyslexia. The other
80% most likely are genetically heterogeneous, which means that there
are many different genetic profiles, each of which can lead to the disor-
der we call dyslexia (see Pennington, 1989 for a good discussion of ge-
netics and dyslexia). Behavior genetics researchers interested in dyslexia
 Current Trends in Dyslexia Research 29

appear to agree that whatever the genetic basis for the disorder, its final
common pathway, at the level of behavior, is a deficit in phonological
coding of spoken and written language. I will have more to say about
phonological coding shortly.
Another interesting program of research that has emerged within the
last ten years has been based upon autopsy studies involving five male
and two female patients with clear diagnoses of dyslexia. When stained
sections of their brains were viewed microscopically at Harvard in Albert
Galaburda's laboratory, it was found that all five males had common
types of anatomical abnormalities that involved errors in the develop-
ment and migration of neurons during the prenatal period. These neu-
rons were found in improper numbers, and improper arrangements,
particularly in language areas of the brain. Only one of the two female
brains had these focal microscopic abnormalities involving neuron
migration. However, both females and one male showed evidence of
scarring of the cortex due to brain injury occurring some time prior to
age two. In none of the seven cases was there clear documentation of
trauma to the brain at birth or during early childhood. Galaburda also
found that the language areas of the left and right hemisphere were of
the same size. This symmetry occurs in only about twenty percent of
non-dyslexic people's brains. Galaburda theorizes that the neurological
basis for dyslexia consists of two anatomical traits: early cortical damage
and lack of the normal asymmetry in the language regions of the brain.
He speculated recently that the problem in dyslexia stems from a failure
by the brain to eliminate the excessive numbers of neurons that are nor-
mally produced during the prenatal period. This results in a deviant "neu-
ral architecture" (patterns of connections among neurons). The deviant
neural architecture underlies the unique pattern of language difficulties
seen in dyslexics. The source of the anatomical abnormalities is unclear
at present, but may be related to improper genetic instructions for both
brain and immune system development (see Galaburda, 1989 for a good
discussion of this).
As a result of these and of behavioral studies, dyslexia is no longer
seen as a specific kind of learning disability involving reading and spell-
ing. It is now coming to be viewed as a language problem with perhaps
several aspects. Researchers are now concerning themselves with the na-
ture of these language problems. Their work has implications for early
diagnosis of dyslexia, remediation, and predictions about later develop-
me nt.
30 Frank Manis

The most common difficulties involve processing the sounds of spo-

ken language (phonological difficulties). These phonological problems
may take several forms. One form involves a difficulty retrieving words
from memory (so-called word finding problems). We see this occasional-
ly in nearly everyone's speech when an individual pauses, momentarily
unable to come up with the word he or she wanted to use. Sometimes
the word is retrieved from memory a few seconds later, other times the
speaker substitutes a definition or a similar word and other times the lis-
tener actually comes up with the word. Studies by Maryanne Wolf and
others (Wolf, Bally and Morris, 1 986) indicate that dyslexics have more
difficulty than non-dyslexics with word finding, and this problem is very
salient at the ages of five to seven.
Another form of phonological difficulty involves keeping an exact
phonological representation of what someone is saying (or what the indi-
vidual is currently reading). This is usually referred to as short-term
memory or working memory. The idea is that proper comprehension of
language involves temporarily storing words and phrases in short-term
memory so that they can be analyzed for their meaning. If dyslexics
make errors in storing exact versions of what they hear or read, or can
only store a limited amount of information, this would interfere with
comprehension. Isabelle Liberman, and her colleagues at Haskins Labo-
ratories in Connecticut (Liberman and Shankweiler, 1 985), have shown
that second and third graders who are poor readers make sound-based
errors in storing information in short-term memory, and this may interfere
with their comprehension of sentences. Other studies have shown that
problems with phonological encoding continue into adulthood among
dyslexics, interfering with oral reading accuracy, reading fluency and, to
some extent, reading comprehension (Aaron and Phillips, 1986; Bruck,
1987).
The most important type of phonological problem has to do with pho-
nological analysis of speech. To understand this problem, you need to be
reminded that spoken words consist of smaller parts known as pho-
nemes. There are forty phonemes in English. Examples include the short
a and long a sounds in cat and cake, the th sounds in think and then, and
the consonants b, d, 1, and h. Dyslexic children have extraordinary diffi-
culty breaking spoken words down into their phonemes. They do not
have as much difficulty separating words into syllables—the phonemes
seem to be the real stumbling blocks. This problem manifests itself as ear-
ly as age four, when most non-dyslexic children can tell you which word
is the odd word out in the series (sun, sea, rag, sock) or the series (nod,
 Current Trends in Dyslexia Research 31

red, fed, bed). This task involves separating words into the initial conso-
nant (called the onset) and the remaining syllable (called the rime). Bry-
ant and Bradley (1985) showed that children who were poor at this task
at age four and five were more likely to become poor readers at age 7 or
8. Studies of adults with a history of dyslexia reveal continuing problems
in dealing with phonemes. One way we have demonstrated this in our
work is to ask people to remove a phoneme from a word and pronounce
what is left. We use nonsense words to prevent them from solving it by
spelling. For example, how would sparf sound without the p sound? Sarf
is the correct answer. We have used this type of deletion test with indi-
viduals from grades two through ten, and the results reveal problems
among dyslexics at every age (Manis, Szeszulski, Holt and Graves, 1 990;
Szeszulski and Manis, 1990). Bruck (1992) found that young adults with
a history of dyslexia often functioned at a third or fourth grade level on
this task. Bryant and Bradley have an excellent book summarizing their
early work (1985). They argue that problems in analyzing phonemes
makes it difficult for dyslexic children to learn to decode printed word., If
you are not aware that sun, sea, and sock share an initial sound, and rag
does not fit in the series, it will be difficult for you to learn a rule that says
the letter s goes with the sound s.
Samuel Orton (1937) and generations of his followers in the educa-
tional realm knew that dyslexic children have difficulty learning to de-
code printed letters to sounds. A variety of structured programs have
been devised to teach them "phonics" rules with some success. What
Bradley and Bryant have shown is that direct instruction in phonemic
analysis has an indirect effect on decoding. For example, they taught
children to separate words into phonemes using pictures and found that
their reading scores improved despite the fact that no direct instruction
in reading was given. By far the best results were obtained when pho-
neme analysis instruction was combined with phonics training by using
plastic letters that could be moved around to track the movements of
phonemes (e.g., note how s moves in sit, nest, and hits (see Bryant and
Bradley, 1985). A recent study by Hatcher, Hulme and Ellis (1994) con-
firms that a combination of phonemic awareness training and decoding
training works better than either alone.
As we learn more about phonological problems, we are beginning to
theorize about various sub-problems of dyslexia, and how they might be
connected to one another. Many researchers are now claiming that the
phonological difficulty is the core of dyslexia. One of the most interest-
ing studies along this line is by Olson and his colleagues at Colorado (01-
32 Frank Manis

son, Wise, Conners and Rack, 1990), in which they obtained data from a
large group of twins, at least one of whom was dyslexic. They tried to
measure phonological skill using games, such as Pig Latin, which re-
quired children to move phonemes to the ends of words, and tests of the
ability to decode nonsense words. Nonsense words cannot be read by
sight, so the child must apply his/her knowledge of phonics (spelling-to-
sound correspondence rules).
Olson and colleagues also created tasks which required the children
to be sensitive to spellings (they called these orthographic tasks). They
asked them, for example, to decide which of two similar spellings was
the correct spelling of a word (e.g. rane vs. rain; dreem vs. dream). Olson
found that the phonological tasks had strong genetic components. That
is, if one member of a pair of identical twins was low in that task, then the
other twin was likely to be high. The orthographic tasks were about
equally related to genetics and to the individual child's exposure to read-
ing materials.
Does this mean that dyslexics have an inherited phonological proces-
sing problem that cannot be overcome? Does it mean they must bypass
phonological processing of printed words and try to memorize them as
individual spelling patterns? That is not the way I read Olson's findings.
Simply because phonological skill is related to genetics does not mean
phonological skill cannot be taught. After all, the amount of muscle mass
you have has a strong genetic base, but you can increase your muscle
mass with certain types of exercises. In the same way, good phonics
instruction can be expected to increase phonological skill. However,
holding curriculum constant, children with high phonological skill are
likely to advance faster. I am currently doing research on the orthograph-
ic component (the memorized spellings of individual words) at Land-
mark. Our initial findings are that over time, dyslexics' progress in
reading and spelling is related to both increases in phonological decod-
ing and memorized sight words. This suggests that you cannot progress
without both components of word reading (Manis, Custodio and Szes-
zulski, 1993).

LONGITUDINAL STUDIES

More and more often these days we are seeing longitudinal studies of dys-
lexia. This is good news because longitudinal studies can shed light on the
early forms that dyslexia takes as well as the long-term outcome. I will dis-
cuss studies that follow dyslexic children into adolescence and adulthood
 Current Trends in Dyslexia Research 33

first, followed by innovative studies of young children who later became

dyslexic. Studies by Margaret Bruck (1987), at McGill University, followed
students who went to college. These showed that three or four factors
were associated with success. I think this is important and interesting, be-
cause as parents, you have already worked on some of these factors. Dys-
lexics who went to college and who did well had a past history of effective
academic remediation. Whether they had been exposed to a good read-
ing program was more important than the reading level they had attained.
Bruck argues that an effective reading program builds self-esteem. This
means that even though the child is not reading at high levels in college,
they have come out of the academic experience with high self-esteem.
Another factor which seemed to be important in Bruck's study was
strong family support that continued through college. There were cases
of dyslexics who had good scores and remediation, but when family sup-
port broke down, they were less successful. The third important factor
was the presence of good academic support services in the college. Sur-
prisingly, a lot of colleges do not do a good job of this, and when col-
leges do and the students took advantage of these services, it was found
that success was more likely. The fourth factor was the intelligence test
score of the students. We know lQ tests measure a large number of poor-
ly defined skills, so it is difficult to say what was going on here. My guess
is that bright students are better able to compensate for the basic lan-
guage processing difficulties in dyslexia.
Turning to the other end of the age spectrum, a recent innovative
study has explored what the early development of the dyslexic child may
be like. Hollis Scarborough (q. v. Scarborough, 1990), a researcher in
New Jersey, found forty families who had an older dyslexic child with a
younger sibling who was approximately two and a half years of age. Of
course the younger siblings had not been diagnosed as dyslexic yet. She
also obtained approximately seventy families with an older child who
was not dyslexic. Each of these families also had a two and a half year old
child. The young children from both the dyslexic and non-dyslexic fami-
lies were given a variety of tests at age 2.5, 3.5, 5.0 and 8 years.
Among the forty dyslexic families, twenty-two of the two and a half
year old children were diagnosed as dyslexic at age eight (by means of
IQ and reading scores). Eighteen of these children who were followed
longitudinally were diagnosed as normal readers at age eight. Scarbo-
rough selected from a larger sample twenty control families without dys-
lexic children who were matched to the families with dyslexic children
34 Frank Manis

on a variety of criteria (sex of child, socioeconomic status, parent's

education level, etc.).
What she found was that dyslexic children had problems learning the
grammar of spoken language at age 2.5. These grammatical problems
were not seen in the eighteen children with a dyslexic sibling who were
themselves not diagnosed dyslexic or in the twenty control children.
These problems were identified by analyzing the children's speech to
their parents in the home. Children who later became dyslexic used
shorter and less complex sentences. The dyslexics did not show unusual
difficulty with articulation, comprehension and did not have smaller than
average vocabularies.
Scarborough's finding is quite novel, because grammar difficulties are
not widely cited as a major problem among dyslexics. They are usually
cited as a minor problem, but not one that is debilitating. At the ages of
three and a half and five the results were the same. At these ages, howev-
er, Scarborough also found that naming and rhyming difficulties were
present in the children who were later diagnosed as dyslexic. So it wasn't
until the ages of 3.5 and 5 that typical phonological problems were diag-
nosed. The grammatical and phonological difficulties found at these
ages were correlated with reading skills at age 8. What this means is that
grammatical difficulties at ages 2.5—5.0 and phonological difficulties at
age 3.5-5.0 distinguish quite well between children with and without lat-
er diagnoses of dyslexia.
Scarborough's findings suggest several interesting hypotheses. First,
phonological problems are not the only or most basic cause of later read-
ing problems, but they are just an indicator that the dyslexic has a differ-
ent developmental pattern. Second, Scarborough's data suggests that
grammatical difficulties in the young child are also part of the dyslexic
"developmental pattern." Finally, the most speculative hypothesis is that
dyslexia may be a computational problem. That is, the language areas of
the brain among dyslexics may not have enough capacity to compute
rules in relationship to language. This deficiency manifests as a different
problem at different stages of development. At age 2.5—3.5, the problem
manifests as figuring out rules of grammar, because at that age this is the
most difficult problem to master. At age five, the most complex problem
is figuring out the language phonetically, and at age eight, the most diffi-
cult problem is mastering the rules and exceptions among printed words.
Studies have shown that dyslexics have learned some of the sounds by
then, but they still have problems figuring out which words fit the rules,
and which words are exceptions (Rack, Snowling, & Olson, 1992).
 Current Trends in Dyslexia Research 35

Scarborough's view is that different manifestations of dyslexia are

seen at different ages, and so it is premature to argue that phonological
difficulties are the single core cause of dyslexia. I think this is a very inter-
esting and innovating way of thinking about dyslexia. It suggests that dys-
lexia is a complex type of language processing problem which will
manifest itself in different ways throughout the life-span. We are only be-
ginning to understand what these manifestations are, and how they differ
from one individual to another.

CURRENT RESEARCH INTERESTS

That leads me to my current research projects, which I will summarize

quickly. With the help of Landmark West and the Torrance Unified
School District, I have conducted a pilot longitudinal study that will help
fill in the gaps in what we know about the development of dyslexics in
the school years (e.g. age 10-16) (Manis et al., 1993). We followed up
21 dyslexic children undergoing intensive remediation (primarily at Land-
mark West). We found that they made almost two years of progress on a
standardized test of isolated word reading. They also made adequate
progress on a test of elementary decoding skills (e.g., pronounce the
nonwords nug and plunc) and on Olson et al.'s (1995) test of ortho-
graphic skill (e.g., which is a word, rane or rain?). However, the dyslexics
made very little progress on more demanding tests of phonological de-
coding (e.g., pronounce two-syllable nonwords), a test of phonological
awareness (e.g., /p/ from /sparf/) and a test of irregular word (e.g.,
beauty, colonel, silhouette) spelling.
These findings coincide with Bruck's (1992) data on phonological
awareness. Phonological skills in general are quite difficult and may nev-
er be fully mastered by many dyslexics. Dyslexics were able to compen-
sate for the phonological problem by learning to recognize words
visually. However, they could not perform the more complex task of
spelling irregular words. Our data, and those of Bruck (1992) suggest ei-
ther that much more attention needs to be paid to preventing or reme-
diating phonological deficits, or that such deficits are very resistant to
training and compensatory remediation is in order.

QUESTION AND ANSWER

Question: What careers and disciplines do dyslexics follow?

Dr. Manis: Bruck (1987) analyzed that question by reviewing four
36 Frank Manis

previous studies. She found a wide variety of occupations represented

with the most common being some type of business. There were a few
dyslexics in professional careers, such as medicine, teaching, etc.
Question: Are phonological problems genetic?
Dr. Manis: Olson's twin study, which I discussed earlier, indicates that
phonological problems have a strong genetic basis. This does not mean
that they can't be ameliorated (or on the other hand) exacerbated by the
environment the child grows up in.
Question: Are these phonological problems synonymous with audi-
tory processing?
Dr. Manis: I would use phonological problems more specifically, as
involving the analysis of sounds of spoken words. Auditory processing
sometimes means auditory comprehension, and, in fact, auditory com-
prehension seems to be one of the stronger areas in many dyslexics with
average or above average intelligence test scores.
Question: Are there studies correlating conductive hearing loss with
phonological problems in dyslexic children?
Dr. Manis: There have not been many studies of this relationship in
dyslexics per Se, but there have been studies, particularly in New Zea-
land and Australia (McGee, 1982) of other children who have conduc-
tive hearing losses, caused by such things as otitis media. This group of
children certainly has more reading problems than average. However, a
hearing problem at age three or four does not always translate into a
reading problem at age eight. Some youngster can compensate, mean-
ing that hearing problems are not synonymous with dyslexia. The major-
ity of dyslexics do not appear to have conductive hearing losses
(Vellutino, 1979).
Question: What about governing bodies who may be attempting to
establish criteria for the identification of dyslexia?
Dr. Manis: We have to ask whether these definitions make use of cur-
rent scientific knowledge about dyslexia. Most of them rely on a discrepan-
cy between intelligence and reading and try to rule out other factors such
as a history of emotional problems or lack of exposure to reading. Howev-
er, all of the terms in the definition are difficult to operationalize and mea-
sure. Ultimately I think the individual family and school has to make a
decision about treatment based on all of the information they have about
the child's developmental history, test scores, behavior, attitude and re-
sponses to previous treatment, rather than rely on a set formula.
Question: What are your views on the formulation of precise defini-
 Current Trends in Dyslexia Research 37

tions of dyslexia, such as those used by consensus in cases of youngsters

with hearing or visual losses?
Dr. Manis: I think everything I've been saying today operates against
a precise definition of dyslexia. First, there is the problem of where in the
continuum of reading or spelling skills you want to make a cut-off. Se-
cond, there is the problem of dyslexic children having a variety of lan-
guage difficulties beyond simply reading and spelling, such as deficits in
phonological awareness and grammatical knowledge. These language
difficulties have an uncertain causal relationship to reading, spelling and
writing. Third, while the neurological and genetic studies help in one way
by showing that some proportion of individuals with reading problems
have a biological basis for the disorder, in another way they raise prob-
lems. There is a danger of over-generalizing the genetic and neuroana-
tomical findings. At the present time we don't have a test that will say
with a certainty which children have a biological basis for their problem.
One day we may have brain imaging tests that work along the same lines
as PET scanners (which show levels of brain activation during a task). Re-
search in this area has been underway for several years now. However, it
is crucial to point out even if we were able to accurately diagnose de-
viant patterns of brain anatomy or function, this does not tell us what the
type and severity of language disorder might be. We have to rely on be-
havioral tests for that judgment. Rather than a single definition of dyslex-
ia, I think detailed descriptions for each child need to be utilized, based
on that individual's areas of strength and weakness in language. E.g., one
child might have a severe physiological problem, mild naming and gram-
matical difficulties, difficulties in oral reading and word attack skills and
normal language comprehension. The label needs to be as descriptive as
possible, and closely tied to areas that can be attacked in a remedial pro-
gram.
Question: To what extent are scores on an lQ test influenced by dys-
lexia? Can they be falsely low, on a test like the WISC, because of dyslex-
ia?
Dr. Manis: Keith Stanovich (1988) has written an interesting article in
which he argues that IQ scores and reading are related bi-directionally.
This means that the skills measured by lQ tests are somewhat predictive
of success in reading, but over time, successful experiences in reading
will exert affect on the IQ test score. For example, poor decoding skills
lead one to read less often and lower exposure to printed texts means
fewer opportunities to learn new vocabulary and new facts. Vocabulary
and information tests figure prominently on tests like the Wechsler lntelli-
38 Frank Manis

gence Scale. Hence, dyslexics over time may show significant declines in
IQ. This means that IQ scores are not falsely low, they are really low. We
need to realize that IQ tests are measures of attained knowledge or skill
that include both genetic and environmental influences. I would advo-
cate giving tests that measure many aspects of intelligence, such as the
Woodcock Johnson Revised test (Woodcock and Johnson, 1989). This
would give a more complete picture of the dyslexic individual's strengths
and weaknesses.
Question: Can dyslexia cause mathematics difficulties? How are the
two related?
Dr. Manis: That is a little tricky to describe, because studies show that
about half of children with severe reading problems have varying de-
grees of math problems. It is tempting to say that there is a common
cause, but I suspect there are many other factors that contribute to math
difficulties. One of the best studies which has attempted to break this
apart was done by Bryant and Bradley (1985) in England. As I mentioned
earlier, they identified the phonological factor by playing a little game, in
which you have to pick the odd word out, such as sun, see, sock and rag,
and then were asked to select out which does not fit. The right answer is
rag, because the others start with as." They also did that with rhymes, ask-
ing the children to select out rhyming words. What they found was that
this type of task predicted later reading difficulties, but not arithmetic
computation difficulties. This suggests to me that difficulties in math
computation are related to somewhat different factors than difficulties in
reading. However, reading skill is bound to be important when doing
word problems, or generally when reading math texts. However, arith-
metic skills, as well as geometric and algebraic concepts are probably
largely independent of reading problems. So, if you have a child with
both reading and math problems, I suspect that there is more than one
underlying difficulty. The math difficulties might be related to visual per-
ceptual difficulties and to visualization of shapes and how well you ro-
tate them, as is seen in some studies (e.g., Strang and Rourke, 1985). It
might be related to memory difficulties involving the storing of informa-
tion of all types, not just phonetic information. Problems with attention
or concentration can cause both math and reading problems, of course.
Beyond that, causes of math problems have not been well studied. We
know about one-tenth as much about mathematics difficulties as we do
about reading difficulties.
Question: Can mathematics difficulties be caused by visual proces-
 Current Trends in Dyslexia Research 39

sing problems, as when trying to process information rapidly from right

to left across the blackboard?
Dr. Manis: There are cases of children who have this difficulty. There
has been more information coming out about mathematics lately, and
about mathematics difficulties among learning disabled children. But a
lot of psychologists think that visual processing problems are isolated
cases, and that problems in mathematics are more often conceptual
problems. For example, a child may not have learned basic arithmetic
facts to an automatic level of retrieval, or not have mastered the place
value concept and how to borrow or carry. By the time the child is ex-
posed to long division, you have to apply rules at a quite rapid rate. Stud-
ies by Arthur Baroody (Baroody, 1987) at Columbia Teachers College,
for example, reveal that children who have problems with math, have dif-
ficulties learning and applying those rules. Some attribute these prob-
lems to poor instruction in the American schools, and say that these
problems don't appear in the Asian schools. There may be some truth in
that. But I think that among severely math-disabled children, the problem
at one level involves slow acquisition of mathematics rules. The underly-
ing cause of the slow rate of rule learning is not clear at this time.
Question: What about motivational factors related to reading com-
prehension?
Dr. Manis: It is hard to find reliable measures of motivation. One of
the ways psychologists attempt to measure this is by giving children a
measure of print exposure, called the "Title Recognition Test." This is a
quick measure of how much a child has read. We present the child a list
of titles of books, including phony titles and real titles, and ask them how
many books they recognize. Cunningham and Stanovich (1990) have
shown that children's responses are related to orthographic skill (i.e.,
knowledge of word spellings) independently of phonological skill. We
have replicated their study and found that the Title Recognition Test
score is also highly predictive of reading comprehension, even when fac-
tors such as intelligence, memory and decoding are factored out. We
think this means simply that children who are motivated to read more
develop better comprehension skills. Of course the data are correlation-
al, so it could be the other way around.
Question: Are you studying the structure of syntax and sentence vari-
ation?
Dr. Manis: No, we don't have a direct measure of that in our studies.
The closest thing we have is a test of how well children can repeat sen-
tences of increasing length and grammatical complexity. We are not
40 Frank Manis

measuring the child's own grammatical ability, as reflected in speech. A

few studies have looked at grammar in poor readers (e.g., age 7-9) and
found them to be somewhat below average (Vellutino, 1979). I'm sure it
does make some contribution to reading comprehension, but I would
think it would make an even larger contribution to writing skills.
Question: How do you test 2.5 year olds—on an individual basis?
Dr. Manis: Certainly we can test your children on an individual basis.
Scarborough (1990) tried to get them to talk about pictures, and re-
corded their speech to parents. Recording spontaneous speech is the
only way you can study language in young children. You can't give them
formal test very easily. They analyzed the speech and recorded, for ex-
ample, how many pronunciation errors were made, etc., and, as I said, it
was found that dyslexics were not unusual in that respect. However, they
were delayed in the development of grammar.
Question: How was it scored?
Dr. Manis: There are regular stages in the development of grammar,
relating to the use of verb tenses such as the present progressive tense,
the use of question forms such as where and why, the use of helping
verbs such as do and is, etc. How far the child had progressed in these
stages was rated by researchers.
Question: What are some examples of these grammatical errors that
Scarborough studied?
Dr. Manis: It was not so much that they were errors, but delays. For
example, when a child wants to say "1 walked up the stairs," he might say
I walk up the stairs." If you see this in a 3½ year old, the child is using an
immature form of grammar for his or her age.
Question: Later might we have the ability to analyze areas of the
brain relative to different abilities?
Dr. Manis: Yes. There have been a few studies which find an associa-
tion between certain abilities and areas of the brain that become active
in the performance of those tasks (e.g., Duffy and McAnulty, 1985). The
way this is done is by asking an individual to perform a fairly well under-
stood task and then determining which part of the brain is active by
means of PET scanning. However, PET Scanners are rare and expensive
and as yet few of these studies have been done. They are an exciting pos-
sibility for the near future. Other studies have examined individuals with
known damage to an area of the brain (q.v., Ellis, 1984). Those studies
have given us some information about which areas are involved in differ-
ent aspects of reading and spelling, as well as other intellectual tasks.
This research is also still in its infancy, however.
 Current Trends in Dyslexia Research 41

Question: What specific kinds of problems have been identified in

dyslexics' brains?
Dr. Manis: The PET scan studies show how the brain works while it is
doing something, that is, they show hot and cold areas, the hot areas in-
dicative of activity. Studies of dyslexics show some puzzling findings. For
example, they show that the motor strip (in an area of the frontal lobe) is
less active in dyslexics as they read (Duffy and McAnulty, 1 985). Howev-
er, nobody knows how that finding relates to reading problems. Duffy's
studies also showed more widespread difficulties extending into the visu-
al and language areas of the brain.
Question: Are motor difficulties a possible cause of dyslexia?
Dr. Manis: I don't know that they are a possible cause, but they cer-
tainly are associated with dyslexia. A study by Nicolson and Fawcett
(1990) was based upon the premise that dyslexics have trouble automa-
tizing any skill. What they did was to have children perform various physi-
cal activities on balance beams, etc., and at the same time count
backwards from 100. What they found was that dyslexics did quite well
on balance beams and the like but when they were asked to count back-
wards at the same time their performance deteriorated. What was strik-
ing was that one dyslexic subject was a pre-Olympic level gymnast, and
even she did poorly on the balance beam when asked to count back.
wards at the same time. What these authors claim is that dyslexia is
broader than just a language problem and involves difficulty taking any
skill to a high level. Certainly, Dr. Cratty's work with motor skills here a
Landmark reveals similar problems with motor coordination in a certain
percentage of the dyslexic population.
Thank you and good night.

REFERENCES

Baroody, A.J. (1987). Children's Mathematical Thinking. New York: Columbia University Press
Bryant, P.E., & Bradley, 1. (1985). Children's Reading Problems. New York: Basil Blackwell.
Bruck, M. (1987). The adult outcomes of children with learning disabilities. Annals of Dysixia:
37, 252-263.
Bruck, M. (1992). Persistence of dyslexics' phonological awareness deficits. Developmental
Psychology, 28, 874-886.
Bruck, M. (1990). Word recognition skills of adults with childhood daignoses of dyslexia. De-
velopmental Psychology, 26, 439—454.
Cunningham, A.E., & Stanovich, K.E. (1991). Assessing print exposure and orthographic pro-
cessing skill in children: A quick measure of reading experience. Journal of Educational
Psychology, 82, 733-740.
42 Frank Manis

Dully, F.H., & McAnulty (1985). Brain electrical activity mapping (BEAM): The search for a
physiological signature of dyslexia. In Dully, F.H., & Geschwind, N. (Eds.), Dyslexia: A
Neuroscientific Approach to Clinical Evaluation. Boston: Little, Brown and Company.
Ellis, A.W. (1984). Reading, Writing and Dyslexia: A Cognitive Analysis. Hillsdale, N.J.: Law-
rence Eribaum Associates.
Galaburda, A.M. (1989). Ordinary and extraordinary brain development: Anatomical varia-
tion in developmental dyslexia. Annals olDyslexia, 39, 67—80.
Hatcher, P.J., Hulme, C., & Ellis, A.W. (1994). Ameliorating early reading failure by integrating
the teaching of reading and phonological skills: The phonological linkage hypothesis.
Child Development, 65, 41-57.
Liberman, l.Y., & Shankweiler, D. (1985). Phonology and the problems of learning to read. Re-
medial and Special Education, 6, 8-17.
Manis, F.R., Custodio, R., & Szeszulski, P.A. (1993). Development of Phonological and Ortho-
graphic Skill: A Two-Year Longitudinal Study of Dyslexic Children. Journal of Experimen-
tal Child Psychology, 56, 64-86.
Manis, F.R., Szeszulski, P.A., Holt, L.K., & Graves, K. (1990). Variation in component reading
and spelling skills among dyslexic children and normal readers. In T. Carr, B.A. Levy
(Eds.), Reading and Its Development: Component Skills Approaches (pp. 207—259).
New York: Academic Press.
McGee, R.O. (1982). A Thousand New Zealand Children: Their Health and Development
from Birth to Seven. Medical Research Council of New Zealand, Special Report Series
No.8.
Nicolson, R.l., & Fawctt, A.J. (1990). Automaticity: A new framework for dyslexia research?
Cognition, 35, 159-182.
Olson, R.K., Wise, B., Conners, F., & Rack, J. (1990). Organization, heritability, and remedi-
ation of component word recognition and language skills in disabled readers. In T. Carr
& BA. Levy (Eds.), Reading and Its Development: Component Skills Approaches (pp.
261 —322). New York: Academic Press.
Orton, S.T. (1937). Reading, Writing and Speech Problems In Children. London: Chapman and
Hall.
Pennington, B.F. (1989). Using genetics to understand dyslexia. Annals of Dyslexia, 39,81—93.
Rack, J.P., Snowling, M.J., & Olson, R.K. (1992). The nonword reading deficit in developmental
dyslexia: A review. Reading Research Quarterly, 27, 29—53.
Strang, J.D., & Rourke, B.P. (1985). Arithmetic disability sub-types: The neuropsychological sig-
nificance of specific arithmetical impairment in childhood. In B.F. Rourke (Ed.), Neurop-
sychology of Learning Disabilities. New York: Guillord.
Scarborough, H.S. (1990). Very early language deficits in dyslexic children. Child develop-
ment. 61, 1728—1743.
Stanovich, K.E. (1988). Matthew effects in reading: Some consequences of individual differ-
ences in literacy. Reading Research Quarterly, 21, 360—406.
Szeszulski, P.A., & Manis, FR. (1987). A comparison olword recognition processes in dyslexic
and normal readers at two reading-age levels. journal of Experimental Child Psychology,
44, 364—376.
Vellutino, F.R. (1979). Dyslexia: Theory and Research. Cambridge, MA: MIT Press.
Wolf, M., Bally, H., & Morris, R. (1986). Automaticity, retrieval processes, and reading: A longi-
tudinal study in average and impaired readers. Child Development. 57, 988-1000.
Woodcock, R.W., & Johnson, M.B. (1989). WoodcockJohnson Psychoeducational Battery—
Revised. Allen, TX: DLM Teaching Resources.
LECTURE 3

James Gardner, Ph.D.

Clinical Psychologist

UNDERSTANDING AND
HELPING LEARNING
DISABLED STUDENTS
TO SURVIVE AND
THRIVE IN SOCIETY

"It is important for teachers, parents, and other students to

understand the real struggles of the learning disabled."
44 James Gardner

Introduction by Richard L. Goldman

Welcome to the Speaker Series. Tonight's speaker specializes in diagnos-
tic and psychotherapeutic work with children and adolescents, and also
with the counseling of parents. Dr. Gardner currently maintains a practice
in Westwood, California. His background includes direction of the Chil-
dren's Center in Venice, California, Chief Psychologist of Children's Hospi-
tal in Los Angeles, and Director of the Psychological Center of Los
Angeles. He has had wide speaking experience. I think some of you saw
his book called the Turbulent Teens when you came in. This book is in-
tended to help parents obtain information, receive encouragement, and
get greater insights enabling them to better assist adolescents with learn-
ing disabilities.
Tonight he will discuss a very important topic, the ways that parents
may understand and help learning disabled students, whom we call "the
frightened survivors in society." It is my pleasure to introduce Dr. James
Gardner.

Dr. James Gardner

Thank you all for coming out tonight. I think this turnout is a tribute to par-
ents who have come out in the evening after a hard day's work. I am al-
ways impressed with parents who attempt to learn more about their
children, and about how to interact with them more effectively.
I would like to thank you all for being here, and I will try to provide you
with something of value in return. We will discuss learning disabilities,
how they extend themselves into life disabilities, and how parents and
others can help. To get us on the same wavelength, I will first describe
how things are with a learning disabled child.
A few minutes ago, a lady asked me if any of my five children had been
learning disabled youngsters. This brought back some of the scenes that
happened with one of our children during the early grades. One of our
youngsters, now a thriving businessman, was dysgraphic as a child. That
is, he had difficulty with written expression. His dysgraphia was diag-
nosed through testing. However, some twenty three years ago, dysgra-
phia was not easily recognized, nor well known (and, except among
experts, remains relatively unrecognized and undiagnosed today).
His mother and I would go to school and tell his teachers that he was
not trying to be sloppy. We explained that he had coordination problems
when writing.
Our son was an excellent reader, and was, and is, very bright. He just
 Understanding and Helping to Survive in Society 45

could not express himself clearly in written form. We finally enrolled him
at the University of Southern California, Reading School. His reading,
however, was not the issue. It was just that at this school, they were will-
ing to reduce the quantity of written work expected of him. They tried to
understand the boy and the problem.
I do, then, have a special slant into some of the problems learning dis-
abled children face, and their families must face. A learning disabled
child warps normal parenting. Often in the family there is a sense of
grieving, feelings that something is wrong emerge, and questions are
raised about whose fault it is. The family seems to have flawed goods and
there is no Nordstroms to take the product back to.
Such a child presents innumerable problems that must be constantly
worked with and assisted. Our family's efforts seemed to have paid off.
As I mentioned, our son is now a successful, educated young man. All of
the effort we put forth has been worthwhile.

THE NATURE OF LEARNING

We first need some understanding of how the learning process works be-
fore we can understand learning disabilities. Initially there is input. This
may consist of visual, auditory, kinesthetic-tactile, or proprioceptive input.
Proprioceptive input or "muscle memory" is important in many ways.
For example, when learning to spell, we know if a word is written five
times (or more) it is more likely to be retained than if it is not written in
this way. It is within the visual-perceptual aspects of learnings, however,
where things can go very wrong for a learning disabled child. Visual sym-
bols seem to twist. The learning disabled child may actually see words or
letters backwards. Letters may be inverted.
Interpreting auditory input may also pose problems. For example, au-
ditory figure-ground problems may arise. When you get to my age, and
you are at a noisy restaurant, you often do not know what anyone is say-
ing .... you say what? what?, get me to a booth please! It is not that your
hearing is bad, it is just that you are are not discriminating sounds as well
as you once did. Many learning disabled children have problems focus-
ing upon important and relevant sounds, while eliminating extraneous
sounds in their environment. Other auditory problems faced by learning
disabled children include auditory lag, and poor auditory memory. In
short, information which does not get into the central processing system
clearly and efficiently, through both auditory and visual modalities, will
not be understood. Thus, the second stage of learning may not take
46 James Gardner

place in an efficient manner. This I will call "The Inner Box." Within "The
Inner Box" is the processing, integration, and storing of information tak-
ing place. After the signals have come in, through one or more sense mo-
dalities, the information must be processed, integrated and stored. These
processed involve the decoding of both visual and verbal information,
the sequencing and synthesizing of information and its analysis.
During the third phase of learning, the person must do something with
the information. Generally this involves either verbal or written output.
Information comes back out in those two major expressive elements. A
problem of oral expression is termed aphasia. If there is a written prob-
lem it is called dysgraphia. Various perceptual or learning problems may
be related in some underlying way. A youngster may, and often does,
have more than one kind of problem, with input, with integration or syn-
thesis, or with output. Sometimes it is difficult to be sure of the problem.
Thus precise diagnosis (through testing and observation) is critical.
Diagnosis of the kind of learning disability which any child can mani-
fest is the core of successful planning for the remediation of the disabil-
ity. We now have many useful diagnostic tools, such as the Wechsler
Intelligence Scale for Children-Revised (WISC), and The Woodcock-
Johnson Test of Cognitive Abilities, Revised. But it is not the test that we
find most useful. An l.Q. test is only a rough screening device. If there is a
problem with limited intelligence, then a child might not be appropriate-
ly placed in a school or class for learning disabilities. When evaluating
learning disabled youngsters, it is often the sub-test analyses which are
most useful. Inspecting the sub-test pattern, for example, we may find
that that child has a sequencing problem, or that a child has problems
with part-whole relationships. A part-whole relationship from an aca-
demic standpoint reflects problems with how well clumps of information
go together, and form coherent wholes. Sorting out the events that hap-
pened at the Battle of Gettysburg, all fit together in sequence to make a
coherent whole, is an example of this process. Thus a child with a whole-
part relationship problem may understand different aspects of clumps of
information, but still may not be able to string them together meaningful-
ly as a 'whole' piece. Through effective diagnostic work we may, then, be
able to identify such problems, and spot other problems involving input,
integration processing and output. Such difficulties may cause problems
not only academically, but also on the job, and even in sports.
If there are academic problems one attempts to locate a top-flight
educational therapist, or in the extreme, enroll your child in a specialized
 Understanding and Helping to Survive in Society 47

school such as Landmark West. With a precise initial diagnosis one is at-
tempting to determine just what is wrong and what should done.

PEER RELATIONSHIPS

The learning disabled child may also have problems with peer relation-
ships. Here a score from a sub-test of the Wechsler may be helpful. If the
child scores low on the sub-test called Picture Completion, he will tend to
evidence difficulties when trying to pick up subtle cues, both academical-
ly and socially. Such children often miss a key part of the instructions given
by the teacher, or remain oblivious to subtle social cues provided by their
peers. Among peers these same children often are the ones who do not
understand the subtle joke, or what just happened, or why Janie is angry
at Betty. They miss the non-verbal cue of the raised eyebrow. They seem
to just to plow ahead, remaining socially oblivious to what psychologists
call incidental cues, and incidental learning. When these children move
through social situations they may sense that others are unhappy with
them. They may not know understand how the mood or direction of the
group changes. They seem unaware of the fact that why they are talking
about no longer fits the conversation. They are still trying to get their two-
cents worth in a topic that has been long-abandoned by the others. They
look and sound awkward, and they are. This problem invites derision di-
rected toward them, and social alienation from others. In these ways the
erosion of their self-concept begins.

SPORTS PARTICIPATION

In sports many learning disabled children are mismatched. Most children

obviously like to play sports and do a pretty good job. The learning dis-
abled child, however, may have both conceptual and perceptual prob-
lems. As I stand here, we all know that the parking lot is behind us, the
office is up there, and Ventura Blvd is over there. Most youngsters on foot-
ball fields, or on basketball courts, or soccer fields, know how players
move around and have a "sense of the court," a sense of the playing field,
and of the spatial relationships involved as they move around.
If a learning disabled youngster, however, does not have that spatial
sense, someone has to help them get it. If they continue to have difficul-
ties, they have to be in a sport in which they succeed. Sports such as
swimming, bowling, bicycling, running and jumping come to mind. The
learning disabled child with problems of organizing spatial relationships
48 James Gardner

does not know what do to. Their coordination may be intact, the drive to
succeed may be there. But they often have little notion of why and to
where all they players are running. The overall conceptual organization is
simply not there. So this kind of problem poses difficulties for kids with
this type of learning disability. Incidentally, the diagnosis of these spatial
relationships difficulties, the poor perception of subtle social cues, and
organizational difficulties can come from parents, as well as from profes-
sionals. Informally, I see these difficulties among my young patients.
When I say the elevator is to the left, as they leave my office, and every
time they walk to the right, you as a parent can make such informal diag-
noses yourselves. Your youngster may not seem to know where he or she
is half of the time.

AT WORK
On jobs, children who are having trouble often evidence problems in se-
quencing, organizing and with writing and reading. Clearly, an individual
who has trouble with reading and writing may well be expected to have
job-related difficulties. However, problems with sequencing, organizing,
and conceptualizing are of a different, though no less important nature. In
a fast-food restaurant, for example, not reacting quickly and correctly may
be disastrous. In such situations when A happens one is supposed to go to
actions, B, C, and D quickly! The employees must do things quickly. They
have to get the french fries, and the hamburger, write it all down and serve
the total meal, and fast. Managers of fast-food chains will tell you that
there are a lot of people who have trouble with that kind of processing.
Some of their employees, they state, cannot make the necessary connec-
tions fast enough, and accurately enough.

IMPROVING ORGANIZING AND PROCESSING

One way in which parents may help their child speed up organization and
processing is to engage in board games, including card games. With some
children we teach card games, using slow moves. We begin slowly, but
with practice we gradually speed up processing and reaction demands.
We might teach the card game Go Fish to a 4th grader who is having pro-
cessing and sequencing problems. Later Crazy Eights may be tried, and still
later, Spit. Normally one must move quickly and make discriminations rap-
idly. In Spit someone puts down the 4, and then another player must play
a 5 or a 3. With the learning disabled child you may start playing these
 Understanding and Helping to Survive in Society 49

games at one-half speed, and even this may be too rapid at first. You have
to experiment to find the right starting speed, and then gradually become
faster as the child can accommodate to processing demands. Parents (or
others) may use more board games at slower speeds when dealing with
younger children who need even more time for processing and integra-
tion. Then as I have indicated, you play the games with increasing speed,
as rapidly as the child's developing skills will allow.
In a classroom if the teacher gives instructions too quickly this same
child will also fall behind, just as he or she does in the games described.
When the child falls behind in class he or she begins to manifest more
avoidance behaviors, since there is inevitable failure and frustration pres-
ent. These avoidance behaviors are strong predictors of failure, since
then the child avoids practicing the very tasks on which he or she needs
intensive work.
Thus parents need to think, not only about exotic training programs, but
also what everyday things can be helpful for a child having processing, se-
quencing, and/or other perceptual dysfunctions. In other words we need
to search for simple exercises that begin where the child is, in terms of
ability, and then later progress by placing greater demands upon the
child's processing speed, dexterity, and performance efficiency.

TUTORS

Tutors are still another tool to be employed against a young person's learn-
ing disability. Sometimes parents must be quite directive with the tutor.
Parents must sometimes tell them how to tutor and what to tutor. Since
most of us as parents cannot tutor our own children effectively, we must
go outside the family when hiring a tutor. But the other side of the coin is
that the tutor, no matter how skillful and experienced, cannot know your
child as well as you do. The tutor, to be most effective, therefore, must be
given additional information and instructions from you the parents. When
we needed a tutor for our dysgraphic son, we found a person experienced
with learning problems, though she had not dealt with dysgraphia before.
So, his mother and I working with the tutor, devised a program which was
very helpful. As our son got older, we found that the final and best help for
him was a word processor. After observing the success of our son, using
this strategy, I have recommended the use of the word processor to many
dysgraphic students, with excellent results.
50 james Gardner

PARENTS

In addition to school and tutors, parents are a third major source of help.
To be most helpful, however, parents often need to rethink their roles.
Sometimes parents are locked into traditional roles. Parents are usually
thought of as value setters, and as those who set the rules. Parents often
pattern themselves after their own parents, or whomever they think are
good parents, and try to be that kind of parent. But as I said earlier, a learn-
ing disabled child will often warp the best efforts at good parenting. What
you thought was going to work will not prove successful: And who you
thought you were, in your parental role does not always suffice when
working with a learning disabled youngster.
One way to re-conceptualize your role as a parent, of a learning dis-
abled child, is to consider yourself as a coach-interpreter type of person,
an interpreter both of life and of life situations. You can never get out of
your traditional parenting roles, those are locked in for most of us. Howev-
er, you can also assume the role of coach/interpreter. This is adouble job.
This additional parent-job is often useful because learning disabled
children are often puzzled by the world around them. They may be con-
fused about what is expected academically of them, or how they should
act with peers, or how they might perform in sports.
Not all children are not having the same problems in all areas. Howev-
er all learning disabled children will exhibit signs of confusion and/or
avoidance in some area(s). A learning disabled child is thus often a
puzzled child, a frustrated child and, too often, a defeated child. Self-es-
teem spirals downward. This in turn produces secondary emotional
problems, over and above the primary problem—the learning disability
itself.
Secondary emotional problems are often manifested differently in
learning disabled boys and girls. Girls tend to become withdrawn, quiet,
even depressed. In contrast, boys tend to act out. A learning disabled
boy would rather be thought of as bad, rather than dumb. Anger is the
cover for the shame of the learning disability.
One approach to understanding learning disabled children, particular-
ly when their behavior appears in distorted forms, is to ask the simple
questions as to whether they are either getting something or avoiding
something by exhibiting such behavior. In this way one can read" the
behavior of children by evaluating the consequences of the behaviors
manifested.
Depressed or angry acting-out behaviors may be less likely among
children whose parents are willing to function as what I have termed
 Understanding and Helping to Survive in Society 51

"coach/interpreters." In this way the parent is translating puzzling as-

pects of the child's world into, hopefully, less puzzling aspects. The par-
ent, as coach, then works with the child by formulating more effective
solutions to the problems, whether these be social, academic, or those
occurring in athletics. In other words, the parents interprets puzzles, and
coaches toward solutions. Three things are needed to be a good coach:
a game plan, a sense of humor and techniques, including the use of time
lines, schedules, schedules, lists, check-off sheets, written notes, as well
as other strategies.

OTHER TECHNIQUES

Walking Through
A useful technique, often used intuitively by many parents and teachers,
may be termed "walking through." "Walking through" involves first model-
ing a job, and then doing it, modeling it again and then doing it again. This
alternation of modeling and doing continues for as many learning trials as
may be necessary.
One might, for example, help a child clean up his or her room, using
the walking through technique. A personal example occurred when we
moved to our new house years ago. Our child with a learning disability
was supposed to join his brothers and sister in organizing each of their
respective rooms. However when faced with this task, he became essen-
tially non-functional. It was not that he rebelled and refused to do the
task, it was that he seemed completely puzzled by it. As all the other chil-
dren put things away, he sat in the middle of the room. He could not or-
ganize the room. He did not seem to know where to start.
Finally his mother and I recognized the problem, and asked his grand-
mother to help him. Granny went in and walked him through the job in
the nicest way. She helped him organize his shirts, socks and pants. She
moved him through the organizational maze slowly and patiently until
the job was done. The room was then organized. All books and clothes
had been put away neatly. Both she and my son were very pleased with
themselves!
This is the walking-through technique. The parental coaching persists
until some sort of criteria has been reached. Practical methods lead to
success. There is no allowance for failure. In this case our son's room was
organized. In other instances, organizational help may be needed for ev-
erything from time management, doing homework, keeping a note
book, to straightening up a school locker.
52 James Gardner

Anxiety Reduction
While consulting to the University of Southern California's Reading
School, and to other specialized schools, I began to perceive that com-
mon to all learning disordered children was much anxiety and the appear-
ance of many avoidance behaviors. Anxiety and avoidance behaviors
would be manifested depending on the task presented and upon the cir-
cumstances. The avoidance behaviors tended to be well-learned, quite au-
tomatic in their appearance, and very functional in the degree of psychic
protection they offered the child.
Since anxiety usually was paired with these avoidance behaviors and
seemed to serve to cue the appearance of such behaviors, we began to
use techniques such as movement to reduce anxiety (large muscle activ-
ity tends to inhibit anxiety). We would ask them to read as they walked
about the room. When we asked them to do this, they not only read bet-
ter but anxiety also was lowered.
Some children with learning disabilities are similar to individuals who
stutter. If you can get the stutterer to do something, such as standing on
his or her head, talking from behind masks, or singing the words, then
stuttering tends to decline. Similarly when you ask children to move away
from a desk while reading, improvement in reading is often noted. By
changing the stimulus cues (from a child crouching at the desk, in front
of a book, to the child walking around the room with the book in hand,
and teacher with arm across the child's shoulders) then anxiety is re-
duced and avoidance behaviors such as looking away, fooling around,
sharpening pencil, tend to decline.

One—Minute Counselor

Another useful technique was formulated by my colleague Dr. Grayce

Ransom, and me, at the University of Southern California's Reading
School. This is essentially a one minute counseling technique for use by a
classroom teacher, a tutor or a parent. Technically the technique is called
"Academic Reorientation,"1 but actually it is a one minute teaching meth-
od. Its implications go far beyond the classroom, for it can be used any-
time and anywhere.
There are three essential elements to one minute counseling (it may
take less than a minute, but longer than minute is too long). These steps
include: (1) helping the child discriminate avoidance behavior she/he is
manifesting. (2) pointing out the probable consequences of this behav-
ior, and (3) offering a more appropriate alternative behavior.
 Understanding and Helping to Survive in Society 53

This is how it works. Charlie, a learning disabled student, is behaving in

a disruptive and inappropriate manner in class. Using the one-minute
counseling technique the teacher (or aide) moves quitely over toward
Charlie, bends down and points out what Charlie is doing (discriminating
the behavior). "Charlie you are looking out the window and that is avoid-
ance behavior. You are doing this because you feel you might not be suc-
cessful with the work" (the explanation of the behavior, and optional
aspect of the approach.
The teacher then describes the consequences. "Charlie if you keep do-
ing this, then you will miss the lesson, you won't finish, and you'll be mad
at yourself." This is followed by the offering of a more constructive alter-
native. "It would be best if you stopped looking out the window and
keep your eyes on the book. Raise your hand if you need any help."
All this takes a few seconds. The interaction is unobtrusive and posi-
tive. There is no anger on the teacher's part, no punishment is given. The
teacher has gone from just teaching academics to helping the child un-
learn negative behaviors, the avoidance behaviors, and begin to learn
and use more appropriate, task-oriented behaviors.
Let's move outside for another example. Charlie is with peers and his
relationships have been shaky. He is becoming louder and more de-
manding and more unpleasant over some incident. Dad moves in and
takes Charlie quitely to one side. "Charlie, you are talking too loud and
becoming too bossy (stage #1). If you keep this up, your friends will not
want to stay here and play with you. (Stage 2). I suggest that you lower
your voice, be pleasant, and ask you friends what game they want to
play, and then play it with them nicely. (Stage 3)." Of course at first all this
is not going to work all the time, or even some of the time. But, throw
enough mud against the bar and some sticks. Keep working with the
child using the one minute counseling method and some will stick. Best
of all, there are no negative side-effects. There is no down side risk to
being decent with the child and trying to teach them strategies and effec-
tive behaviors that they need to know.

Circle Back

Paired with the one-minute counseling method is "circle back technique."

To employ this method, the teacher, parent or coach, first uses the three
stages of the counseling technique (discriminate, point out consequences,
offer constructive alternatives). Then the teacher or adult moves away
from the child momentarily. Then the adult circles back toward the child,
and if the child is manifesting any part of the new, alternative behaviors,
54 James Gardner

the adult reinforces the child with a touch, a murmured word, or with a
meaningful glance.
In short the attempt is made to eliminate the old behaviors and to re-
place them with new, more positive ones. To do this, the child's initial
attempts at the positive behaviors must be reinforced by the adult. Later
the child will be reinforced by their success with academics, with social
success with peers, or while participating in sports.
Psychotherapists working with children often use the one minute
counseling framework. However, the professional often adds one more
level to the technique, that is, a more thorough interpretation of why the
child is doing the unwanted behavior in the first place.
If parents attempt to use complicated reasons for why the child is ex-
hibiting avoidance such as "it is because of a conditioned fear of failure
which interferes with effective learning!", then the parents may cause
Charlie to throw up, or at least be turned off to their words. Thus we
counsel parents to avoid voicing deeper level interpretations. Parent
should stay with explaining what they see, what they think the conse-
quences might be. Parents should not be too dire, but should rather be
immediate. The child does not relate well to being told that he or she will
not go to college if a behavior is continued.
But as Charlie's therapist, I can sit in my office with him and explore his
overt behavior as both he and I see it, and as expressed in school reports.
But in counseling I can also draw diagrams. We can practice new behav-
iors, on his part. We can practice all three parts of the brief counseling
technique, and we can also delve a bit deeper into why the behaviors
occur in the first place.

SUMMARY

A new role has been suggested for parents of learning disabled children.
The role of parent—coach interpreter of the world. In general it is a three
part role. The first job is to assess the positive or the negative aspects of
your child, acting as a diagnostician. Then you should come up with a
plan. What are the goals? How can you help? Who else should be brought
into the plan?
Next ask yourself what techniques are available, and how might these
be employed to teach the goals you have set? Most parents (and others)
tend to be OK with the first two aspects, but fall somewhat short on
deriving techniques. But techniques are fairly plentiful if some imagina-
tion is used. These can range from using different kinds of sports to em-
 Understanding and Helping to Survive in Society 55

ploying board games, and can include the use of movies and music. Your
child can be assisted in developing a full repertoire of social behaviors
and task oriented behaviors, and will not have to fall back to using avoid-
ance or other negative behaviors.
Parents may model many forms of appropriate behavior, using the
walk through technique I have described. This can include using tasks at
home, such as how to reorganize dishes when placing them in the dish-
washer, as well as how to clear out and reorganize a garage, notebook or
desk. Thus an emphasis should be placed upon organization, on how to
get from here to there easily and successfully. There is also an emphasis
upon helping your child to stop shooting themselves in the foot, with
maladroit classroom and social behaviors.
The various techniques I have described are seen as ways of empower-
ing and enabling parents.
Most of us are at our worst when we can think of nothing positive to
do. As parents, we then may yell, shout and punish, but that doesn't offer
our child much on the positive and constructive side of things.
I have known people who seemed to feel that if they just talk louder to
a person who does not understand English, the person will finally "get it"
in some manner. The same loud, useless talking may occur between a
parent and child. Parents who have no useful techniques to use often
tend to just become louder and/or more punitive. However, if parents
reconceptualize their roles as parents, to the broader role of coach—in-
terpreter—trainer—teacher-model, and then bring into play some of the
techniques discussed (and others which you will create) your child will
be the direct beneficiary.
Using these techniques should minimize your anger, and help you to
think of teaching and learning trials. As you and your child go through a
procedure one more time, and then again, low and behold things will
begin to stick, and you will begin to see positive behavioral changes in
yourself and your child.
Thank you.

QUESTIONS AND ANSWERS

Question: What kinds of techniques can you use to enhance the sub-
tie nuances that children don't have? Those nuances with peers relations
you have described, and things of that sort?
Dr. Gardner: This type of thing may sound more difficult than it actual-
ly is. What is a subtle nuance? What is a subtle nuance? Basically, it is a
56 James Gardner

shading of a behavior that means something, and is usually important to

pick up and not miss. Examples might range from picking up the differ-
ence in a Shakespeare class when asked a question about Richard Ill,
when the instructor means the play, not the man, or using an arched eye-
brow or a certain tone of voice in other contexts. But your question
asked, how do you teach the ability to spot and to react to subtle
nuances?
Movies can be used. While watching, for example, the Breakfast Club,
you might ask questions such as: "What does that mean? Why did he do
that? What do you think he feels about her? Does that gesture mean that
he is going to beat someone up?" Comic strips can also be used. Since so
many kids now watch MTV, that there is almost always a channel (no pun
intended) to be explored. You might ask the child as you both view a pro-
gram. "What is that image?, or perhaps, What is an image supposed to
do?"
Question: How many times do you have to show a child how to orga-
nize a dishwasher, before you realize that the child is exploiting you, and
you end up doing it. He really wanted you to do it. What do you do at
that point?
Dr. Gardner: If that is what you suspect, exploitation, and most par-
ents instincts are pretty good in this regard, then you might have to say
"Organize any way you want to but the fact is that you can do it a lot
faster and more efficiently if you do it this way." Actually I haven't found
that exploitation or manipulation to be the important factors in these sit-
uations on the part of most children. Also, if the child is being manipula-
tive then you have to ask, why is the child showing such behavior? Most
children aren't born wanting to be manipulative, or mean to our parents.
Parents are people who children love.
Thus, you have to ask yourself why is this happening? and What is go-
ing on here? Are you as a the parent setting up parameters that are teach-
ing the child to be devious and/or manipulative? But if you feel that you
are being manipulated on some task, such as organizing the dish washer,
or giving homework help, then stop doing it.
Question: How do you deal with teenagers who react to guidance as
criticism?
Answer: You have to ask yourself, as the "coach," what is the best
psychology to approach this player with now? Don't forget you know his
or her conditioning history better than does anyone else. Perhaps in the
past you have leveled so much criticism that maybe you can no longer
just switch over to the role of coach. The child may feel very bruised.
 Understanding and Helping to Survive in Society 57

However, you might sit down together in a restaurant, which by its nature
will likely promote civilized and low-key behavior, and become able to
talk about the problem.
You might say "look I think I have been doing something wrong here. I
believe I have been overly critical over the years. I did not mean to hurt
you. But, perhaps I have made you overly sensitive to suggestions, and
you read suggestions as criticism. I am just saying that I feel I have got
something to offer, but I realize that my way is not the only way or even
necessarily the best way. But let's try to work it out together." In this way,
the teen is brought into the problem-solving and communication pro-
cess.
However, nothing works all the time. You have to be prepared for that.
We can formulate the best-laid plans for assisting a young person, and
just have them simply not work. In such a case it's back to the drawing
board and another attempt is made to figure it out all again until you
have something that really works.
As parents, you keep trying. There's no alternative.
Question: As an educator what should I do about a child missing the
social clues you talked about?
Answer: Speaking generally if the student seriously misreads another
student's statement, or intent or something like that, I think it would be
appropriate for you to say something like. . . "1 think you misunderstood
what Mary said" . . . and then let them work out their communication
again.
Teacher response: What if I really don't know? What if it is about the
war and I really don't know what is going to happen? I really believe it is
expressing their own fear.
Dr. Gardner: These are really psychological issues as opposed to
avoidance behaviors. When I find out they are afraid, or that it is a ter-
rible misconception . . . like my mother says "this is the beginning of
World War Ill!" Then it is appropriate to correct the balance. You might
perhaps note that the Gulf Crisis is really not the beginning of World War
Ill, although some people might think so. I would try not to undermine
the parent, but there is a need for a balancing statement to the child. We
adults are often the reality much of the time for children. We must feed
them back a balanced reality. Children live in a magical world for many
years, a world that is half logic and half fantasy. We know that the sense
of reality and logic for children is different than that of adults. The
change from children's thinking to more adult thinking begins to take
place around puberty. Nevertheless, no one of us is a fully logical crea-
 58 James Gardner

ture. But our children don't become logical by never learning more
about reality and logic.
Question: How did you explain your son's learning disability to a com-
plete stranger who knows nothing about learning disabilities, knowing
how competitive parents can be?
Dr. Gardner: Regarding our own son, I explained it straight forwardly.
I could not help if they (others) didn't understand every subtle nuance of
learning disabilities. I thus explained that "Our son has a problem in ex-
pressive language, he has a problem in putting words out his fingers.
Though there is no problem in language, he speaks, well, but his hand-
writing is poor."
If the stranger asks. . . "Is it brain damage? I would respond as follows.
"I don't think of it as brain damage, although it used to be considered
brain damage, I consider it more a deficit or deficiency in the hard wiring
of the brain. It is like a TV set. In one little area all the wiring has not
grown it, so we are just helping the wiring grow in."
If a stranger asked "What is caused your son's problem,?" I would an-
swer "Nobody knows for sure. About one-third of children's learning dis-
abilities are from birth defects, another third (or more) are caused by
genetic factors, and the rest are caused by unknown factors. By the way,
usually a stranger who asks this many questions is really seeking informa-
tion about one or his or her own children.
Question: I have problems when placing my son in a new school,
when I change schools he has no friends.
Dr. Gardner: This is not just a problem with learning disabled children.
There are a number of children who have trouble making friends. Some
psychologists think that if you haven't mastered "friend making" abilities
by five to seven years, he or she will have trouble down the line. We see a
lot of children who are social isolates, or even social misfits. Parents have
worked very hard with such children. You have to choose their schools,
camps, and other groups they might enter, with care. Pay special atten-
tion to the qualities and skills of leaders.
I have no glib or simple answers for this problem. Look for areas of
common interest. Athletics is great, of course. But forcing a child with
low skills into sports may do more harm than good. Art programs,
Scouts, Computer Programs and others all can be useful. But there are
not easy answers here. If possible try to place your child in situations in
which there are more, rather than fewer, other children. (A big public
school versus a small private school, a housing tract versus an isolated
 Understanding and Helping to Survive in Society 59

house in the hills). I realize this cannot always be an accomplished be-

cause of other factors.
Considering the hour, let me offer to stay and talk individually with any
of you who may have further questions.

NOTE

1. Gardner, James, and Ransom, Grayce. Academic Reorientation: a counseling approach

to remedial readers. The Reading Teacher, 21, 529-536, 1968.
LECTURE 4
Steven Forness, Ed.D.
University of California, Los Angeles
Professor of Psychiatry and Biobehavioral
Sciences, School of Medicine
Principal of In-Patient School,
Neuropsychiatric Institute

SOCIAL AND
EMOTI ONAL
DIMENSIONS OF
LEARNING DISABILITIES

"As an adult reporter, I cover news conferences, and even now

someone will say a name that I can't quite process as fast as
others; so I raise my hand and say, 'Will you please spell that?"
62 Steven Forness

Introduction by Richard L. Goldman

Tonight we are really fortunate to have as our speaker Dr. Steven Forness.
Dr. Forness is a professor and Director of the Interdisciplinary Training Pro-
gram in Developmental Disabilities at the Neuropsychiatric Unit at the
University of California at Los Angeles. He has done significant research in
the field and has co-authored five books, including The Science of Learn-
ing Disabilities and The Handbook of Learning Disabilities. In addition, he
has written over 100 articles in professional journals. The topic tonight,
"Social and Emotional Dimensions of Learning Disabilities," is a crucial
topic for all professionals and parents. Without further ado, it is my plea-
sure to introduce Dr. Steven Forness.

Dr. Steven Forness

Thank you, Rick. It is really my pleasure to be here tonight. The Landmark

School has a reputation which is absolutely unparalleled in the field of
learning disabilities. Just a couple of weeks ago, I recommended a young
woman to the Landmark College back East. She is now going through the
acceptance process. This was an interesting process to go through. The
process was not what I am used to in recommending students to go on to
college; to have to provide WISC profiies to a university's admissions offi-
cers.
But it is a pleasure to be here tonight, especially because Dr. Jack
Cratty is here. I want to say that I live a mortal terror that some day I will
get a call from Jack. He was on my dissertation committee some twenty-
three years ago, and I live in high anxiety that one day Jack Cratty will call
and say that he has found another flaw in my dissertation, they are re-
scinding my doctorate, and my whole career will go up in smoke.
Speaking of anxiety, we are going to talk tonight about some emotion-
al-behavioral disorders and the overlap between those and learning dis-
abilities. This is an interesting topic, particularly for people in public
schools. This is because people in public schools like to place people
with problems or disabilities in particular categories. There is only room
for one problem in each category, as you might know, particularly if you
have gone through the process of special education eligibility in public
schools. If you have a learning disability, you can not be seriously emo-
tionally disturbed, and if you are seriously emotionally disturbed, you
cannot have a learning disability. If you have either one of those, you cer-
tainly can not have a speech and language problem. This has impeded
 Social and Emotional Dimensions of Learning Disabilities 63

our research in looking at the problem of what I call "co-morbidity,"

which is the occurrence of two or more disorders in the same individual.
I am going to speak of this tonight.
I would like to begin by taking a look at some of the figures in public
schools, the way we identify children in the various categories, and in-
spect the trends in identification in the four largest categories in special
education. These include learning disabilities, emotional, and behavioral
disorders.
Then I would like to shift gears and talk about three psychiatric disor-
ders that are the most common seen in child mental health clinics. I will
also look at the co-morbidity of learning disabilities in these kids. This is
based on a series of research studies that we have done in the areas of
conduct disorders, attention deficit disorders and childhood depression.
Then I would like to look at a summary of research on "sub-types of
children with learning disabilities," the different underlying processing
disabilities. There are about five major consensus sub-types of learning
disabilities, and I would like to look at the particular social or emotional
behavioral disorders that kids in each sub-type might have. Then I will
talk about the treatment that might be appropriate for such disorders.
You will see that my own learning disability is an auditory processing
problem; I need visual aids, so I am going to do everything with tables
tonight.
The first table is constructed from about sixteen different appendices
of the Thirteenth Annual Report from Congress on "Individuals With Dis-
abilities Education Act." This is the new term for the original Public Law
94—142 (U.S. Department of Education, 1991). This table has the four
largest categories of special education: "Learning Disabilities" is the larg-
est category, next are "Speech and Language Handicaps," then "Mental
Retardation," and then the category of "Serious Emotional Disturbance."
(See Table 1.)
These data are interesting because you can see that the number of
kids in each of those categories in the first column were being scored in
1976—77, just when the law was beginning to be enacted. This is, in ef-
fect, a baseline year, during which we really did not have mandated spe-
cial education in any significant degree for kids across the entire country
in any of these categories. The next column is the most recent year for
which there are data. The data are delivered not only from each state's
public schools, but also from the state hospitals, psychiatric hospitals,
and private schools that receive special education money. Thus, it is a
64 Steven Forness

Table 1. Number of Children Served in Four Handicapping Conditions in the

United States and Its Territories over a Thirteen-Year Period.

%Of %Of
Child School % In
Years Years Popu- Enroll- Main
Category 1976—77 1989-90 Difference lation ment Stream

Learning
Disabled 782,713 2,064,892 160% Gain 3.5% 4.8% 78%

Speech
Impaired 1.1 71,378 976,186 18% Loss 1.7% 2.4% 95%
Mentally
Retarded 820,290 566,150 38% Loss 1.0% 1.2% 28%

Emotionally
Disturbed 245,481 382,159 38% Gain 0.7% 0.9% 44%

Percents rounded to the nearest Hyndreth. Total pupils served are 4.3 million, or approxi-
mately 9.8 percent.
Source: Thirteenth Annual Report to Congress on Idea (1991).

pretty complete count of all children in these major categories of special

education.
Then, the next column shows you the gain and loss in each of these
categories. The next two columns show kids in each category as a per-
centage of the overall population of children between the ages of zero
and twenty-one. The next column is probably the most relevant one, be-
cause it shows you those kids as a percentage of all kids enrolled in pub-
lic schools or in private schools, at public expense.
What is most interesting about this table is that learning disabilities in
the public schools. That growth has become the point where nearly half
of all our children in special education are now identified in the "Learn-
ing Disability" category.
There are about eight major categories in special education, and the
four largest are on this table. The other categories, children with physical,
visual, hearing and multiple handicaps, comprise fewer than ten percent
of all kids in special education. Almost ten percent of total school enroll-
ment are kids in special education. These four categories on the table
comprise ninety percent of all kids in special education. As I noted,
"Learning Disabilities" is almost as large as all the other categories put
 Social and Emotional Dimensions of Learning Disabilities 65

together and is now almost five percent of the total public school enroll-
ment.
The next category, "Speech and Language Handicaps," has suffered a
slight decline in numbers over the years. People are not too concerned
about that because they feel that such decline is a result of increasing
recognition of the language basis of learning disabilities. Thus the chil-
dren who might ordinarily be diagnosed as having a speech and lan-
guage handicap, if it impacts their achievement, are now probably
placed in the "Learning Disability" category. They do indeed have learn-
ing disabilities, but, before, some may have been placed in the "Speech
and Language Handicap" category in most states.
The other category, "Mental Retardation," as you can see, has de-
clined considerably. What is interesting about this category is that many
people do not think that those kids are being served in the "Learning Dis-
ability" category any more. They might have been at the outset. To diag-
nose a kid with learning disabilities in the public schools, we use a
"Learning Disability Discrepancy Formula," that takes into account how
significantly behind mental age or lQ a child's academic achievement is.
There has to be a significant discrepancy between IQ and academic
achievement.
It is pretty clear from the table that a lot of kids now that are being
identified in that category of "Mental Retardation" are probably kids with
more severe mental retardation who do not have an lQ high enough to
be diagnosed as "Learning Disabled." Those with an IQ too low to be
diagnosed as having a learning disability, but too high to be diagnosed as
having mental retardation, unfortunately, are probably not being served.
I am only being partly facetious when I note that if we wait long enough,
they may end up in the next category, "Serious Emotional Disturbance
(SED)." That category is for children who have serious emotional/behav-
ioral problems as a primary handicapping condition. As in all these cate-
gories, children with SED supposedly do not have other handicapping
conditions. They have problems in school because they have anxiety dis-
orders, schizophrenia, psychosis, attention deficit disorders, conduct dis-
orders or a variety of other psychiatric or mental health diagnoses. You
can see that this category is fairly small, composed of fewer than one
percent of all school age kids.
If you think that only one percent of school age children have emo-
tional/behavioral disorders severe enough to impact their educational
performance, then "Have we got a bridge to sell you." Most people think
that, at a minimum there should be probably two percent of kids in that
66 Steven Forness

Table 2. Comparison of Changes in Children Served Between 1976—1977 and

1989—90 in California and the United States.*

Currently % CA % In
Served in School Main-
Category U.S. California California Enroll stream

Learning
Disabled 160% Gain 235% Gain 246,619 4.7% 71%
Speech
Impaired 18% Loss 14% Loss 94,355 1.8% 94%
Mentally
Retarded 38% Loss 38% Loss 24,355 0.4% 5%
Emotionally
Disturbed 38% Gain 45% Loss 12,032 0.2% 10%

Percents rounded to the nearest Hyndreth.

Source: Thirteenth Annual Report to Congress on Idea (1991).

category. Many people also feel that in the "Learning Disability" catego-
ry, some kids have emotional/behavioral problems that may have af-
fected their educational performance. They are thus placed in the
learning disabled category, even though they are not what we think of as
having a learning disability.
The next table is even more problematic in that it gives us comparable
figures for the state of California (see Table 2). California has an even
greater growth in the LD category than the rest of the nation. This state is
now in the bottom forty percent of all states in terms of proportion of
kids in the "Learning Disability" category. In the "Speech and Language"
category we have declined considerably and have substantially declined
in the category of "Mental Retardation," which is at four tenths of one
percent of the school enrollment. In the category of "Serious Emotional
Disturbance," we are identifying only two tenths of one percent of
school enrollment in this category of special education in California.
When I say "in special education," this includes mainstreamed kids who
are receiving special education services in a regular class or resource
room. This is not just kids in special schools, special classes and the like.
Since only two tenths of one percent of kids are getting served in the SED
category, we probably also have a fair number of kids with emotional/be-
 Social and Emotional Dimensions of Learning Disabilities 67

Table 3. Diagnosis of Learning Disability.

Public Law 94—142 (Individuals With Disabilities Education Act")

stresses the following:
1. that a learning disability is a dysfunction in one or more of the basic
psychological processes involved in understanding or using written or spoken
language
2. that there exists a discrepancy between intellectual ability and attainment in
reading, writing, spelling, calculating, listening or speaking
3. an absence of sensory or motor handicaps, mental retardation, psychosocial
disadvantage, or primary emotional disturbance

havioral disorders, maybe not truly having learning disabilities, being

served in the "Learning Disability" category in California.
The reason that I highlight this is to indicate that everything I say from
here on in probably has social relevance for California.
Let us now look at the diagnostic criteria for learning disabilities in
Public Law 94-142 (Table 3). You probably know this by heart if you
have gone through any of the eligibility process for special education in
the public schools. As you can see, this is a category that seems to stress
that learning disabilities is an underlying processing dysfunction in one
of the areas involved in understanding written or spoken language.
The second thing it stresses is that there is a discrepancy between IQ
and academic achievement. That difference has to be in one of the major
academic areas: Reading, math, and written language. As you might
know, in the Federal law, if you have a disorder only in spelling, that is not
a learning disability according to public school law. The reason for that is
it would probably put about fifty percent of us in the "Learning Disabil-
ity" category, me included.
The last criterion requires that we exclude from this category kids who
have mental retardation, hearing handicaps, blind, visual handicaps, or
physical handicaps. We also exclude kids with psychosocial disadvan-
tage and, supposedly, kids with primary emotional disturbances. A lot of
other states actually have a much higher proportion of kids in their cate-
gory of "Serious Emotional Disturbance" because they exclude those
kids from the "Learning Disability" category. California, however, tends
not to exclude kids from the "Learning Disability" category if they have a
primary emotional disturbance, if they meet the other criteria for learn-
ing disabilities.
68 Steven Forness

Table 4. Federal Criteria for "Serious Emotional Disturbance" (SED) Diagnosis.

Limiting Conditions
Classification of disorders (all must be met)

I, Inability to learn that cannot be 1. Exists over a long period of

explained by intellectual, sensory, time,
or health factors.
II. Inability to build or maintain satis-
factory interpersonal relationships
with teacher or peers. 2. (Exists) to a marked degree,
III. Inappropriate types of behavior or
feelings under normal circumstances
IV. General, pervasive mood of sadness 3. Adversely affects educational
or depression. performance,
V. Tendency to develop physical
symptoms and/or fears around 4. Must not only involve social
personal or school problems. malajustment.

The reason I mention these things to you is to give you a sense of some
of the imprecision we have in defining and diagnosing learning disabili-
ties in public schools. In effect, we do not often know, particularly in
California public schools, what we have when we have a child with a
diagnosis of learning disability. There is a good chance a lot of other han-
dicapping conditions are associated with that diagnosis, some of which
you would not find in the learning disability category in other states.
Now having said that, let us look at some of the criteria used to diag-
nose "Serious Emotional Disturbance" in the public schools (Table 4).
These criteria are pretty much the same in California as they are in feder-
al law. They are presented here in outline form. To qualify as having "Seri-
ous Emotional Disturbance" in the public schools, a child has to have a
problem in one of the five areas shown on the left-hand side of the table.
The full wording of the first category is: "An inability to learn which can-
not be explained by intellectual, sensory or health factors." Doesn't that
sound like a Reader's Digest version of a learning disability? It is. If I had
to come up with a learning disability definition in a dozen words or so,
that is probably the definition I would use. This is, however, the very first
criterion used to qualify a child as eligible for special education in the
public schools under the category of "S ED."
 Social and Emotional Dimensions of Learning Disabilities 69

Interestingly, the next criterion area is "an inability to maintain satisfac-

tory interpersonal relationships with teachers or peers." How many of our
learning disabled kids often have that problem . . . an inability to build
relationships, having problems making friends with kids, having kids
choose them as friends, and problems with authority figures, teachers
and the like?
The next criterion is 'inappropriate types of behavior or feelings under
normal circumstances." That supposedly relates to the diagnosis of disor-
ders such as schizophrenia in which there may be inappropriate, bizarre
types of behavior. There is, however, no real definition of any of these
five criteria, so we do not know if this indeed refers to the symptoms of
schizophrenia.
The next one is an interesting one in that it refers to 'a general, perva-
sive mood of sadness or depression." This criterion does seem to refer to
the diagnosis of childhood depression as we know it in the field of psy-
chiatry. This is, however, the only criterion of the five that seems to relate
to a specific mental health diagnosis.
The last criterion seems to relate to anxiety disorders. It is 'a tendency
to develop physical symptoms and/or fears around personal or school
problems." Unfortunately, we do not know for sure if the children exhibit-
ing this have anxiety disorders. There is, as I have said, no further defini-
tion of these five criteria in federal or state laws. Therefore, we have to
proceed on the basis of these symptoms however poorly defined, It is
clear, however, that, if a child has a psychiatric diagnosis of depression,
schizophrenia, anxiety disorders, or attention deficit disorders, such
diagnoses in no way automatically qualify him/her in the SED category.
As the table indicates on the right-hand side, once a child qualifies in at
least one of those five criterion areas, that problem must exist over a long
period of time, It must also exist to a marked degree. In other words, it
must be severe. Note that this category in the public law is called "Seri-
ous Emotional Disturbance." It is the only category with a word 'serious"
in front of it. We do not, for example, serve just those with severe mental
retardation or just the deaf in special education, we also serve those with
mild mental retardation and the hard of hearing. This is the only category
with such a restriction. The third item is also a problem area. It refers to
an 'adverse effect on educational performance." This qualifier is some-
times very narrowly interpreted to mean just academic performance and
not social functioning in the classroom.
And, lastly, a child can be excluded from this category if his problems
can be considered only 'social maladjustment." As with all of these other
70 Steven Forness

statements, "social maladjustment" is not further defined in the law. If

you consider possible definitions or meanings for "social maladjust-
ment," I think the best definition would be almost the same as the se-
cond SED criterion, "the inability to build and maintain satisfactory
interpersonal relationships with teachers and peers." So, on the one
hand, if you have interpersonal relationship problems, you are "in"; and,
on the other hand, if you have them, you are "out".
We are, unfortunately, stuck with this definition, which, as you can see
in at least a couple of important respects, overlaps the "Learning Disabil-
ity" category quite substantially, particularly with criteria one and two.
Now, having said that, let's look at three psychiatric or mental health
diagnoses based on some research we have been doing at UCLA that
examines this overlap with learning disabilities. The first diagnosis is that
"Attention Deficit Hyperactivity Disorder" (ADHD). Kids with ADHD
seem to have significant problems with inattention, impulsive behavior
and hyperactivity. Their symptoms are that they fidget a lot, seem to run
around a lot, can not seem to sit still in their seat, have problems paying
attention, have a lot of problems sustaining attention and they behave in
a very impulsive fashion, i.e., they seldom seem to think before they act.
In the classroom, if you give them a worksheet, they will start marking the
answers before they have actually read all of the questions or before they
have considered all the possible choices for the correct answer. Often
the kid with his hand up first in the air is also the one with the wrong
answer.
These youngsters evidence a syndrome we used to know as the "hy-
perkinetic child syndrome," or what we used to call "hyperactivity." It is
now known as "Attention Deficit Hyperactivity Disorder." This is, unfortu-
nately, a very common psychiatric diagnosis. In fact, it is probably one of
the most common reasons for referrals to psychiatric clinics. It is also a
diagnosis that overlaps a lot of other diagnoses, such as learning disabili-
ties. Common estimates suggest that thirty to fifty percent of all kids with
attention deficit disorders might also have a learning disability. So,
youngsters with ADHD are a big share of those referred to special educa-
tion classes for learning disabilities.
Further, what is interesting about ADHD is that we used to think it dis-
appeared around the onset of adolescence, i.e., that about puberty
these little hyperactive kids would lose their symptoms and no longer
have ADHD. This no longer seems to be true. ADHD seems to persist
well into adolescence and even adulthood. It turns out that the risk for
these folks developing other psychiatric disorders or even adult criminal
 Social and Emotional Dimensions of Learning Disabilities 71

Table 5. Sample of 55 Boys With Attention Deficit Hyperactivity Disorder.

ADHD
with
Variable ADHD CD/ODD
NumberofSs 27 28
Percentage of Minority Ss 11.1% 10.7%
Age (years) 9.6 (1.2) 9.3 (1.1)
WISC-R: Full Scale IQ 106.7 (13.3) 105.8 (11.1)
Verbal IQ 106.7 (13.9) 103.7 (11.7)
Performance IQ 105.6 (13.1) 108.7 (13.1)
Attention Cluster 8.9 (2.6) 8.9 (2.4)
Verbal Cluster 11.2 (2.7) 10.9 (2.2)
Perceptual cluster 11.1 (1.4) 11.6 (2.7)
Reading Recognition Screening Test 5.1 (2.4) 4.6 (2.1)
(grade level)
Reading Comprehension Screening Test 5.2 (2.8) 4.6 (3.3)
(grade level)
Reading Diagnostic Test (grade level) 4.8 (2.8) 3.8 (1.7)
Math Diagnostic Test (grade level) 4.9 (2.2) 5.0 (1.7)
Number meeting modified LD discrepancy 4 4
formula of one standard deviation

behavior is really quite substantial. The follow-up studies on some of

these kids into adulthood are actually quite grim. Unfortunately, it can be
a tragic disorder because we do not always recognize it for what it is and
get immediate help for these kids.
We studied a group of kids with ADHD, on a National Institute of
Mental Health Research Grant, over the last five years (Forness, Youpa,
Hanna, Cantwell & Swanson, 1 982). They were carefully diagnosed as
having "Attention Deficit Hyperactivity Disorder." We also divided them
into two groups. One group had only "Attention Deficit Hyperactivity
Disorder" and no other psychiatric disorders. Please refer to Table 5.
They are in the first column on this table. Another mixed group had
ADHD and also had a diagnosis of conduct disorder. Conduct disorder is
a psychiatric diagnosis for kids who have very serious problems in follow-
72 Steven Forness

ing rules: Aggressiveness, stealing, and a variety of very serious behav-

iors. It is not necessarily synonymous with juvenile delinquency. It is a
psychiatric diagnosis; as it turns out it also may have very poor outcom-
es. But both of these diagnoses, "conduct disorder" and "attention defi-
cit hyperactivity disorder," are diagnosed by a child psychiatrist or
psychologist using DSMIII—R (American Psychiatric Association, 1987).
The diagnosis of ADHD can, however, be quite variable. To be diag-
nosed with "attention deficit disorder," one uses a list of fourteen symp-
toms of which a child has to have at least eight of those symptoms. There
is a lot of uncertainty in which eight need to be diagnosed. For conduct
disorders, there is also a list of thirteen different symptoms, and a child
has to have only three. There is variability in that diagnosis as well.
As carefully as we could, we specified five different diagnostic "gates,"
or diagnostic reviews, that this first group in the first column had to meet
in order to be diagnosed as ADHD. The group in the second column also
had to meet these same criteria and, furthermore, had to meet criteria for
conduct disorder. The table shows that these kids are fairly equal in age
and IQ. It is interesting that their IQ profiles also matched. On their
WISC profiles, both groups are actually doing pretty well on their under-
lying language sub-tests and in their perceptual sub-tests. Both groups,
however, are doing very poorly on the sub-tests that measure attention,
concentration and memory.
Now, here is what is interesting: The group that only has "Attention
Deficit Hyperactivity Disorders" is doing pretty well academically. They
are at grade level in all the academic tests we gave them, and that in-
cludes the Peabody Individual Achievement Test, the Woodcock Read-
ing Mastery Test, and the Key Math Test. The group of kids who had
attention deficit disorder and conduct disorder are academically doing
very poorly, in contrast. They score a semester to a year below grade lev-
el on most academic tests. When we try to diagnose learning disabilities
in both of these groups of kids by using the California formula for the
learning disability discrepancy between IQ and achievement, no kids in
either group qualified as having a learning disability. We then "overrode"
the formula on the evidence that the IQ of these kids was artificially low-
ered because they had low subtests on the IQ having to do with their
attention, concentration and memory. Our diagnosis of a learning dis-
ability could then be reasonably based on a smaller discrepancy. Even
then we only got four kids in each of these groups (roughly about fifteen
percent of this sample) qualifying as having a learning disability.
These results were replicated by Linda Shaywitz of Yale University
 Social and Emotional Dimensions of Learning Disabilities 73

Table 6. Sample of 67 Children With Conduct Disorders.

Diagnosis N (%) Age (SD) Male Minority SP .ED.

Conduct Disorders 10 (15%) 11.1 (1.6) 90% 40% 40%

Conduct disorders
+ Others 18 (27%) 10.0 (2.2) 94% 50% 33%
Atypical CD 21 (31%) 0.6 (2.1) 71% 40% 9%
Atypical CD + LD 18 (27%) 10.2 (2.4) 83% 33% 89%

who was one of the first, along with our group, to use a learning disability
discrepancy formula to properly diagnose learning disabilities.
There is thus an overlap between learning disabilities and attention
deficit hyperactivity disorder that is really much smaller than we used to
think. Probably only ten to twenty percent of all kids who have attention
deficit disorders have a learning disability when properly diagnosed. This
is still a large number of children, because between two and five percent
of the population have "Attention Deficit Hyperactivity Disorder." If we
look at ten percent of those, we still have a fairly large percentage of kids
who would be in this situation.
Let us look at another psychiatric diagnosis that is highly associated
with learning disabilities, and that is the diagnosis of conduct disorders
itself. We studied sixty-seven children diagnosed as having "conduct dis-
order" which, as I said before, is a cluster of severe symptoms involving
aggression, rule breaking, lying, stealing and the like (Forness, Kavale, &
Lopez, 1992). Their difficulties are usually diagnosed as conduct disor-
ders only if they seem to be a relatively stable and enduring set of behav-
iors in a child.
In our study, we found four types of kids with conduct disorders (see
Table 6). In one group, fifteen percent had only conduct disorders with
no other problems. In another group, about twenty-seven percent had
conduct disorders, but their primary diagnosis actually turned out to be
another psychiatric disorder such as "attention deficit disorder," "anxiety
disorder" or "depression." Although they had "conduct disorder" symp-
toms and could be diagnosed as having a conduct disorder, that diagno-
sis often masked an underlying problem such as "depression," "anxiety
disorder" or, in some cases, even "childhood schizophrenia."
Almost a third (3 1%) had more mild forms of "conduct disorder" in
which they were oppositional to adults, did not obey rules and gave
74 Steven Fomess

adults all sorts of problems, but the behavior was not severe enough to
qualify as having a conduct disorder in the formal sense. They were diag-
nosed as having either "adjustment disorder" or what psychiatrists call
"oppositional/defiant disorder."
The last group (2 7%) had a conduct disorder but also qualified as hav-
ing a learning disability. They apparently would have had a learning dis-
ability even if they did not have the conduct disorder. In essence, there
were two disorders in the same child, and it was very clear after psycho-
educational testing that these kids did indeed qualify as learning dis-
abled in California, but in many other states would not qualify because
they had a primary emotional disturbance. It turned out that nearly nine-
ty percent of the kids in this last group got special education. Most of
them received it through the "learning disability" category, not under the
category of "emotional disturbance." Children in the other three groups
had a relatively slim chance of getting into special education, particularly
in California, because so few kids ever make it into that category of "seri-
ous emotional disturbance."
Now let me turn to what we consider a more internalizing psychiatric
disorder, depression. "Internalizing" is a term that psychiatrists use to sig-
nify a disorder in which the symptoms are within the person, as opposed
to "externalizing," in which the symptoms are directed to other persons.
In "depression" there are four clusters of symptoms: The depressed
mood, a withdrawal or inability to enjoy things, physical symptoms such
as sleep disorders or loss of energy, cognitive symptoms around self-es-
teem or preoccupation with morbid thoughts. A child usually has to have
symptoms in nearly all of these areas to qualify as having a clinical diag-
nosis of depression. We looked at a group of 111 kids who met all these
symptoms of depression and were being diagnosed or treated in our out-
patient department (Forness, 1988; Forness & Sinclair, 1 990). What we
found was relatively interesting (see Table 7). We found that forty two
percent had only a diagnosis of "depression" and nothing else. We found
probably another thirty four percent who actually had a diagnosis of "de-
pression" but also had another diagnosis, such as conduct disorders, anx-
iety disorders and sometimes even attention deficit disorders.
The last group we studied had something in common with these other
two groups. They were diagnosed as depressed and often diagnosed as
having acting out disorders, but they also had learning disabilities. It
looked as if they would indeed have had a learning disability even if they
were not diagnosed as depressed. This is consistent with other articles
we have reviewed that suggest that kids with depression may be at risk
 Social and Emotional Dimensions of Learning Disabilities 75

Table 7. Sample of 11 1 Children With Depression or Dysthymia.

Diagnosis N (%) Age (SD) Male Minority SP .ED.

Depressed or
Dysthymic (only) 47 (42%) 10.2 (2.3) 67% 41% 21%
Depressed or
Dysthymic
(co-morbid) 38 (34%) 10.9 (2.8) 68% 24% 44%
Depressed or
Dysthymic
(with LD) 26 (23%) 11.4 (2.7) 62% 31% 85%

for learning disabilities (Forness, 1988; Maag & Forness, 1991). These
are more than just kids who are are demoralized, sad and frustrated be-
cause they have learning disabilities. These kids have serious symptoms
that are severe enough to meet criteria for a clinical diagnosis of depres-
sion.
You can thus see that psychiatric diagnoses may place a child at risk
for having learning disabilities. Let us look now at the reverse. Do learn-
ing disabilities put one at risk for having a psychiatric diagnosis? That may
actually be the case. It makes sense to a lot of teachers of kids with learn-
ing disabilities who observe emotional/behavioral problems in their kids.
It also makes sense that teachers of kids with serious emotional distur-
bances observe that many of their kids have learning disabilities.
Table 8 summarizes literature on more than a dozen different studies
on subtypes of kids with learning disabilities. In these studies, a group of
kids with learning disabilities were classified by their underlying cogni-
tive processing disorders that we referred to earlier, and these have been
reviewed by Weller and Strawser (1987).
They summarized all of these studies that had been done up to that
date. They also looked at the different subtypes of learning disabilities,
not only in terms of the cognitive underlying processing problems that
these kids have, but also at the social or emotional problems these kids
have.
There are five subtypes that have been found to exist consistently
across all of these studies. The first subtype is "non-verbal organization
disorders," what we ordinarily term "perceptual motor problems." These
kids had 'earning disabilities that seemed to be the result of underlying
76 Steven Forness

Table 8. Subtypes of Learning Disabilities, Classified by Their Underlying

Cognitive Processing Disorders.

Type Problems % of LD

1. Nonverbal Organization • Visual-spatial-motor deficits

Disorders • Possible social misperception!
withdrawal 11—15%
2. Verbal Organization • Poor understanding/use of
Disorders language
. Possible agression/acting out 14—17%
3. Global Disorders • Multiple deficits in processing
• Possible problems in all coping
skills 8—10%
4. Production Deficits • Inefficient cognitive strategies
• Possible inattention!
hyperavctivity 22—30%
5. Non-LD Pattern • Discrepancy from grade but
not lQ
• Possible frustration, absences 25—38%

problems in visual perception skills—visual, motor, perceptual, and spa-

tial kinds of skills. It turns out that this group of kids within the "learning
disability" category comprise about eleven to fifteen percent with learn-
ing disabilities, one of the smaller subgroups.
A child who has visual perceptual problems probably has problems
making sense of what he sees on the page. That is why he/she may have
problems in reading. They tend to reverse letters, reverse whole words,
and the like. What is also interesting about these kids is that this problem
may generalize to their social skills as well. When these kids have visual/
perceptual problems, they also can not seem to make sense out of a so-
cial situation because of their perceptual deficits. One of the problems is
"figure/ground perception." When I am up here talking, everybody, I am
sure is not always paying attention to me. For the most part, however,
you are generally able to screen out the noise of the table projector, the
noise of the traffic going by, and the like. These kids can not necessarily
screen out the kinds of other, distracting stimuli in the environment, par-
ticularly visual stimuli. As a consequence, when they are in social situa-
 Social and Emotional Dimensions of Learning Disabilities 77

tions, they are often distracted by a lot of other things going on. They can
not always tell what they are supposed to be looking at or paying atten-
tion to in social situations. They ignore some of the other important stim-
uli.
It is also clear that these kids tend to withdraw in social situations be-
cause they are bombarded by a lot of visual stimuli. As a consequence,
they may evidence withdrawal, or even be at risk for depression. We are
not certain, because this research is far too new and no one has yet ex-
amined these kids in more detail in order to arrive at a clinical diagnosis.
The next subtype is called "verbal organization disorders." This sub-
type has to do with subtle, underlying language processing problems. It
is a subtype comprising about fourteen to seventeen of all kids with
learning disabilities. These kids have subtle, underlying language prob-
lems that may not be severe enough to be diagnosed as a "primary lan-
guage disability," but that interfere with the ability to read because they
do not have a substantial enough grasp of language to relate it to the
visual letters on the page. Social or emotional problems can occur when
these kids do not feel comfortable with the language process and get
frustrated in social situations. They often act out their frustrations. These
kids may thus be at risk for acting out or aggressive behaviors and be
eventually diagnosed as having conduct disorders.
Not every child who has these disorders, in either language processing
or visual perceptual processing, is at risk for psychiatric disorders. If they
have a tendency to develop a psychiatric disorder, it might be in line with
the different kinds of cognitive disabilities that occur within the "learning
disability" category.
The next category is interesting because it is composed of children
who have disorders in both of those areas. And that, thankfully, is a small
subtype. Sometimes those kids are so impaired in social skills that they
have pervasive problems in areas of making friends, keeping friends,
knowing what to do in a social situation, and the like.
The fourth category is the largest identifiable subtype. It comprises
probably twenty to thirty percent of all kids with learning disabilities and
these kids have inefficient cognitive strategies. They can not seem to use
their language or perception to talk or guide themselves through tasks,
or through difficult academic subjects or through social situations. These
are the kids who are at risk for having attention deficit disorders. They
often do not have good impulse control nor good attentional skills. As a
consequence, if kids have this problem, they might be at risk for a psy-
chiatric diagnosis such as attention deficit disorders.
78 Steven Forness

Lastly, the largest group are kids that, on good psychoeducational test
batteries, show up as having no cognitive processing problems whatsoev-
er. They still, however, have a discrepancy between their lQ and their aca-
demic achievement. Sometimes this is seen in kids who have high lQs and
are functioning close to their respective grade levels. They are almost in
the gifted range so they never get identified as learning disabled in school,
or they may have low lQs and be functioning below their IQ, but not far
enough below to qualify them as having learning disabilities.
Some of these will indeed find their way into the "learning disability"
category. What is interesting about these kids, is that they comprise the
largest subtype of learning disabilities in research studies to date. How-
ever, these kids do not have a demonstrateable underlying disorder in
one of the processing or cognitive functioning areas, disorders they are
required to have in order to qualify in the public schools as having a
learning disability. Thus, many will be at risk for dropping out of school
or developing a variety of social or emotional disorders.
In summary, if a child has a psychiatric diagnosis, he or she seems to
be at risk for having a learning disability. If he/she has a learning disabil-
ity, it does not necessarily mean he/she is going to have a psychiatric
diagnosis. There may, however, be somewhere in the neighborhood of
twenty-five percent of all kids in the "learning disability" category who
might indeed turn out to have an identifiable psychiatric disorder. The
vast majority may not. All psychiatric diagnoses are on a continuum. You
and I know that all of our kids with learning disabilities have a variety of
emotional or behavioral problems just as a result of having this learning
disability. They are usually not serious enough to be diagnosed as having
a clinical diagnosis and meeting criteria for mental health services. I just
want to alert you that these two diagnostic categories in special educa-
tion, the two systems of special education for kids with learning and with
mental health problems, have a great deal in common. You need to be
aware of this relationship and be on the alert. Sometimes the normal
frustration and demoralization that occur with learning disabilities may
spill over into having an identifiable psychiatrist diagnosis for which this
child may need help from a psychiatrist, psychologist, or a mental health
clinic. There are clinics, such as the NPI at UCLA, which do specialize in
the emotional or behavioral disorders of children with learning disabili-
ties and related disorders. Not all mental health clinics or practitioners
may be experienced in this area and may thus fail to provide truly inter-
disciplinary treatment that these children require.
 Social and Emotional Dimensions of Learning Disabilities 79

QUESTIONS AND ANSWERS

Question: Category 5 looks like it would be the most difficult when it

comes to getting that child special education services. Could you com-
ment on how to do that?
Dr. Forness: I assume you are talking about the fifth LD subtype rather
than the fifth criterion in the SED category. It is interesting, in a mental
health clinic we can give IQ tests, which often you are not allowed to
give in public school. For example, L.A. city schools will no longer give
lQ tests for their "learning disability" category because of a recent inter-
pretation of an earlier class action lawsuit on minorities not being given
lQ tests because such tests do not reflect their cultural backgrounds.
There is a possibility that public school psychologists could use the lQ
tests only to look at the underlying clusters of the IQ to determine wheth-
er or not these kids actually have an underlying processing disorder and
not use the lQ itself. I do not know if it is ever even approved that only
isolated subtests of the lQ could be used to show that a kid does have
processing disorder and, therefore, has a learning disability, even though
the use of the IQ to establish a discrepancy is proscribed. Many people
are actually using processing tests that are not part of the lQ test, like the
Detroit Test of Learning Aptitude, for example, the Illinois Test of Psycho-
Linguistic Abilities, the Bender Visual Motor Gestalt Test, and the like, in
trying to establish that maybe these kids have problems in underlying
processing disorder who would thus qualify as LD. When you look at
kids who do poorly on some of these tests, their performance on a full
battery of tests will not really qualify them as LD. However, on an iso-
lated test they will qualify.
In a clinic I can give a diagnosis of "learning disability" to a child who
has a discrepancy between IQ and achievement and with whom I have
ruled out other causes of the learning disability such as poor instruction,
physical problems, and the like. Then I can diagnose a learning disability.
I have to do that extra step of identifying a processing problem, however,
when I go to the public schools to get that child services. Maybe about
twenty or thirty percent of our kids in the L.A. public schools may not
qualify as having learning disabilities because they have a discrepancy as
shown on testing in a clinic but do not have both a discrepancy and a
processing problem as needed in the schools. The sad news is that we
may have kids with learning disabilities who qualify in our clinic, who
qualify here at Landmark, but who do not qualify in the public schools of
California because of the restrictive public school criteria.
80 Steven Forness

Question: When you said that kids with emotional disabilities have
learning problems, do you mean cause and effect?"
Dr. Forness: Yes, the speculation is, in depression, for example, that
both depression and the learning disability might be caused by a com-
mon neurologic problem (Forness & Kavale, 1985, 1991). There are
some studies using sophisticated brain scans of patients with depression
that suggest that they might have neurologic abnormalities. There are
also studies that suggest that kids who have learning disabilities may
have some neurologic abnormalities. There have been some suggestions
in some of those studies, which are very preliminary, that some areas of
the brain that seem to be effected in children or adults with depression
may be some of the same areas of the brain that are effected inchildren
with learning disabilities. Again, remember that depression, conduct dis-
orders, and attention deficit disorders are all found to be associated in
some children. Thus, "discipline" problems and learning disabilities
could result from a common cause.
There are two other theories, in answer to your question. One is that
having a learning disability puts you at risk for frustration and withdrawal.
That might in turn place you at risk for depression and related conduct
problems. The other theory is that if you have depression, that may put
you at risk for learning disabilities because emotional/cognitive prob-
lems may make it more difficult to concentrate on academic tasks. All
three of those hypotheses are still open.
Question: If you have a child diagnosed as having a learning disability
and depression at the same time, and if the learning disability is treated,
would that affect the depression as well?
Dr. Forness: There are a couple of answers to your question, one of
which is that it is very hard, even for clinicians, to sort out the demoraliza-
tion stemming from having a learning disability, versus depression from
other sources. We have seen a lot of kids who come into our hospital
unit that have a learning disability and depression. We have a good inpa-
tient school for kids admitted to the psychiatric hospital. Sometimes,
however, the progress they make in the classroom on their learning dis-
ability seems to result from the treatment they are receiving for depres-
sion rather than anything special that is happening in classroom
remediation.
It may be that what we are doing with such a child, in relation to cogni-
tive or social therapies or even the psychopharmacology used for de-
pression, may also improve their general attitude, their concentration or
even their neurologic processing. This, in turn, may not completely
 Social and Emotional Dimensions of Learning Disabilities 81

"cure" learning disabilities, but at least may help improve overall aca-
demic improvement.
This is all speculative, and there are no studies to suggest that is the
case, but it is pretty clear that there are also kids in our clinic or hospital
who have been treated for depression, and their depression improved;
yet they still have learning disabilities.
We also have a number of studies on kids with learning disabilities
who also have social skills deficits. It may be that the only reason we see
a high level of social skills deficits in kids with learning disabilities is that
at least some of these kids have social skills deficits, in whom the social
skills problems are not due to learning disabilities per se, but are due to
other types of psychiatric and behavioral disorders. We need to rethink a
lot of our assumptions about kids with learning disabilities, and whether
social skills are inherent in LD or are more a result of the co-occurrence
of LD and psychiatric disorders.
Question: Why is attention deficit disorder part of the category of psy-
chiatric disorders? I do not see the connection.
Dr. Forness: It is interesting that there is no diagnostic criteria for atten-
tion deficit disorders anywhere that is formally accepted, except for a few
sources. The first is ICD-9, which is the International Classification of Dis-
eases in Children. It is under the psychiatric heading in that classification.
The second is DSMIII—R, which is a psychiatric diagnostic manual.
The major recognition of attention deficit disorders thus comes
through the mental health system. Pediatricians also diagnose attention
deficit disorders, but generally use the ICD—9 criteria. It is possible that
ADD is considered a major mental health disorder not only because it is
so often diagnosed by psychiatrists, but because it puts one at risk for
other psychiatric disorders. There is also a shift in our thinking about psy-
chiatric disorders recently because of recent findings in genetics, bio-
chemistry, and neurophysiology related to psychiatric disorders; and
attention deficit disorders has genetic, biochemical and neurologic fea-
tures that link it with other psychiatric disorders.
Question: What steps are being taken to change the criteria in Califor-
nia as a result of this research that has been done to categorize these kids
as "LD?" What steps are being taken in California to change what Califor-
nia perceives as learning disabled?
Dr. Forness: In California not much is being done at present. National-
ly there are some steps being taken that I hope will impact California's
recognition of these problems.
82 Steven Forness

Question: Would that interest and work be under the Department of

Education then? Because you said nationally it is...
Dr. Forness: Yes it is under the U.S. Department of Education, not un-
der the California Department of Education. Perhaps there may be some
changes made in the Federal Law definition for "serious emotional dis-
turbance" impacting both the mental health system and the SED criteria
in California. These changes involve changing SED to "emotional or be-
havioral disorder" (EBD), so kids who have a primary attention deficit dis-
order or a conduct disorder can be served.
If this happens California will feel a lot more confident in changing its
learning disability definition to exclude kids who have a learning disability
based on primary emotional problems, because then they would get ser-
vices in the new EBD category. I am a member of the National Mental
Health and Special Education Coalition, and my colleagues and I have
written a new definition of emotional/behavior disorders that coalition
has adopted at the federal level. It has now gone to Congress, and we are
about a year away from getting that legislation passed in Congress. If we
do get it passed, probably about a year or so later, California will have to
change its SED criteria and broaden the scope of the kids that are served
in the SED category, Hopefully, then, that will lead to a more clear cut
learning disability diagnosis and will exclude kids from the learningdisabil-
ity category if they have primary emotional problems, because they can
be served more appropriately in that second category. Also in the new
SED category, we are making a provision which hopefully will change the
Federal Law to make it possible for kids in any category to get mental
health care related services. Right now, a child usually gets related ser-
vices in mental health under Public Law 94—142 if he or she is only in the
SED category. If you are in the LD category, you ordinarily do not get re-
lated mental health services funded for or provided by the school. So
those would be a number of important developments that I hope will hap-
pen and would eventually affect the LD category in California.
Question: There are a lot of babies addicted to drugs in Los Angeles.
They are now starting to hit the schools and there is a big concernwith
public schools about not being able to handle them. Probably part of the
reason that they do not categorize a lot of these kids is because they can
not handle them anyway. If they were identified, they do not have the
teachers or the wherewithal to take care of them. But all of these kids
who are coming through now who are born of mothers who were ad-
dicted to drugs, will get funding through mental health. Would they be
 Social and Emotional Dimensions of Learning Disabilities 83

under that already, and what is going on regarding learning disabilities

with those kids?
Answer: One thing a number of folks are worried about with the drug
babies is that they may end up in the learning disability category and
may take slots that are available for kids who are learning disabled. What
we are facing right now in California and other states is a limit on special
education funds. As you know, there is a special education backlash in
terms of a feeling that it is not good to be in special education, that we
can serve children better in the regular classroom.
This movement is called the "Regular Education Initiative" and it
seems to imply that kids with learning disabilities, emotional problems
and so forth would be taken care of primarily in the regular classrooms.
One of the problems is that that backlash is encouraging Congress and a
lot of legislators in the various states not to provide as much money for
special education as they might ordinarily give.
I see a real battle developing in regular and special education between
these new populations coming into special education between those
due to attention deficit disorders, prenatal substance abuse, child abuse
or neglect who are needing to be served being placed in SED or learning
disability categories and then there not being enough room for kids who
normally would diagnosed as learning disabled.
Many people have commented on cocaine babies as a potential prob-
lem in special education. Regarding crack cocaine babies, in our pro-
gram at UCLA Judy Howard is one of the experts in that area. Judy is very
concerned that those kids will probably not fall into the category of
"mental retardation" because they are not severe enough. She thinks
that a number of them may fall into the "learning disability" category or
not have problems that are readily identifiable in existing special educa-
tion categories.
It is not clear whether they will have a discrepancy between their IQ
and achievement. It looks to me like some of these kids will look like kids
who have attention deficit disorders. In California, we do not exclude
kids with emotional/behavior disorders from the LD category. So those
children with parental substance abuse might fall into the learning dis-
ability category and be served there. So everybody is a little bit worried
about what that portends for the diminishing resources and the increas-
ing number of kids, especially in the LD category. The most recent fig-
ures I have seen suggest that forty percent of live births at Martin Luther
King Hospital now are crack cocaine babies. The overall national figures
84 Steven Forness

in inner-city hospitals are ten percent of live births. So you can see the
magnitude of the problem.
Question: Based on the new information you said about the finding
that kids do not outgrow ADD and go through adulthood with the same
symptoms, what does that mean in terms of the child who is on Ritalin
who initially was told, "a couple of years ought to do it?" What is the dan-
ger of keeping the child on Ritalin for long periods of time?
Dr. Forness: It is not feared, as it once was, that Ritalin may be harmful
over the long term. Earlier studies suggested that there may be diminu-
tion in growth with some of these kids, some may not gain weight nor
height as rapidly as other kids who are not on Ritalin. Those studies' con-
clusions may have been premature. It turns out that there may not be
that many adverse effects if Ritalin is used wisely, which means having a
good child psychiatrist or pediatrician who knows how to use Ritalin,
who knows how to use the minimal doses to get the best effect, and who
gives the kids "drug vacations" over the summer, and other precautions.
It also does not look like those kids are necessarily at risk for being drug-
dependent or being drug abusers. It may be that the reason those kids
are drug abusers is not because they are on Ritalin, but because they
have attention deficit disorders. They abuse the drugs primarily because
they have attention deficit disorders. They abuse the drugs primarily be-
cause they have poor judgement and impulse control problems and not
because they are on Ritalin.
There are now adults who are being prescribed Ritalin, adults who
have never been on Ritalin before. As a matter of fact, I myself was a con-
trol subject in an adult Ritalin trial at UCLA. There are a lot of studies go-
ing on, work with adolescents and with young adults who are being
given Ritalin; and it seems to be very therapeutic. Now again, I have to
hedge my bets on saying that we are still studying its use with adults, so
all the data is not complete. I have to also tell you, as I said before, you
have to have a good pediatrician or pediatric neurologist or child psychi-
atrist who knows what they are doing with the drug.
Question: You made reference to an unfortunate prognosis for adult
ADD persons. Could you elaborate on that, assuming proper Ritalin con-
trol, for example, and coping strategies throughout adolescence, what is
the prognosis beyond that?
Dr. Forness: For a good outcome in attention deficit disorders, it is
very clear that there needs to be three components to treatment. One is
medication, another is family therapy and/or parent training and the
third is educational therapies and classroom modifications. These moda-
 Social and Emotional Dimensions of Learning Disabilities 85

lities of therapy seem essential for a good outcome. Even these do not
always guarantee a good outcome, but on the follow-up studies, the
folks who had all three different modalities combined for reasonable pe-
riods of time seemed to have a good adjustment at follow-up as adults. If
you drop out any of those therapies, then the prognosis drops dramati-
cally. If you use two of the three, then the prognosis is not good, but not
as grim as nothing at all.
Generally speaking, the long-term prognosis for untreated ADD in
adolescence or adulthood may be the appearance of disorders such as
depression or other psychiatric disorders, underemployment, or even
criminality.
Question: If treatment should continue through high school level, can
you hope to have the child back into the full mainstream by late adoles-
cence?
Dr. Forness: The issue here has to do with the variability of all these
symptoms. If you remember, the diagnostic process I discussed for atten-
tion deficit disorders or conduct disorders might involve as many as four-
teen symptoms. So there are all sorts of reasons to kind of hedge your
bets when making predictions. The best I can tell you is that, with early
and effective treatment, some cases may well involve a good outcome
even well before late adolescence. Others may continue to need treat-
ment well into adulthood.
Question: I was just wondering about treatment of ADHD within the
future. I know at UCI Child Development Center, it seems like I heard of
their using behavior modification, cognitive behavior, generalization
maintenance, parent training. Do you see some of these components be-
ing transferred to Public Schools? I know Dr. James Swanson has just
thirty percent of his kids on medication there. It just seems like the
technology is out there to help kids almost normalize.
Dr. Forness: There are a number of people who are trying to initiate
effective programs in the public schools. As you know, the U.S. Depart-
ment of Education has given grants on attention deficit disorders and
made recommendations for both regular and special education. Hope-
fully, one of their recommendations will be to provide specific training to
teachers on the kinds of things that seem to work with these kids so that
they can be initiated early on in regular classrooms and even delivered in
more intensive fashion in special education classrooms.
Question: It seems like the techniques are out there in the literature. I
think I have read some of these things since the late 1970's.
Dr. Forness: The techniques are in the literature, not only for this, but
86 Steven Forness

for several related areas in learning disabilities. There is, however, a tre-
mendous lag between their development and their implementation into
the regular classroom, and that is the problem. We currently have the will
and the way, but effective ways of training teachers in knowledge and
skill to deliver these services, and the funds to insure that these aspects
of school reform are carried out are not always available.
Question: Do you think group therapy is more effective than individu-
al therapy for children with learning disabilities and emotional disorders?
Dr. Forness: At particular ages, group therapy may sometimes be
much more important than individual therapy, because peers may be a
better source of support and insight, especially peers who have the same
problem. It can sometimes be a lot more therapeutic than telling
troubles to a shrink who is an adult and with whom a youngster may not
necessarily feel comfortable. Group therapy and individual therapy may
often be recommended in tandem, particularly when insights gained in
individual therapy need to be "tried out" in the safe environment of sup-
portive group therapy. I cannot really recommend one over the other,
but I can tell you that group therapy is a really very important adjunct,
particularly with kids with learning disabilities who do not often have a
chance to sit down and talk about the problems they are having, not only
problems with reading and writing, but about making friends, feelings of
isolation or frustration, and the myriad problems associated with grow-
ing up, all of which can be complicated by having a learning disability.

REFERENCES
American Psychiatric Association (1 987). Diagnostic and Statistical Manual of Mental Disor-
ders (Third Edition — Revised). Washington, D.C.: Author.
Forness, S. 1988. School characteristics of children and adolescents with depression. Mono-
graphs in Behavioral Disorders, 10, 177—203.
Forness, S & Kavale, K. (1989). Identification and diagnostic issues in special education: A sta-
tus report for child psychiatrists. Child Psychiatry and Human Development, 19,
279—301.
Forness, S. & Maag, J. (1991). Depression in children and adolescents: Identification, assess-
ment and treatment. Focus on Exceptional Children, 24, 1—19.
Forness, S., Youpa, D., Hanna, G., Cantwell, D. & Swanson, J, (1992). Classroom instructional
characteristics in attention deficit hyperactivity disorder: Comparison of pure and mixed
subgroups. Behavioral Disorders, 17, 115—123.
Forness, S., Kavale, K. & Lopez, M. (1993). Conduct disorders in school: Special education
eligibility and comorbidity. Journal of Emotional and Behavioral Disorders, 1, 101—108.
Kavale, K. & Forness, S. (1985). The Science of Learning Disabilities. Austin, TX: Pro-Ed.
U.S. Department of Education (1991). Thirteenth Annual Report to Congress on the Imple-
mentation of the Individuals with Disabilities Act. Washington, D.C.: U.S. Office of Spe-
cial Education.
Weller, C. & Strawser, S. (1987). Adaptive behavior of subtypes of learning disabled individu-
als. Journal of Special Education, 21, 101 -116.
LECTURIE 5

Michael Spagna, Ph.D.

California State University Northridge
Assistant Professor of Special Education

ALL POOR READERS

ARE NOT DYSLEXIC

"Please remember not to give up on yourself."

88 Michael E. Spagna

Introduction by Richard L. Goldman

Welcome to everyone. Tonight's speaker was a teacher at Landmark West
several years ago and after leaving Landmark, has considerably expanded
his interests.
Dr. Michael Spagna is currently an Assistant Professor of Special
Education at California State University Northridge (CSUN). He served
for three years as the Coordinator of Services for Learning Disabled Stu-
dents at the University of California Berkeley. He received his M. A. in
Special Education at University of California Los Angeles (UCLA) and his
Ph.D. from University of California Berkeley. Dr. Spagna has also studied
Neuropsychology at the Medical School in the Free University in Amster-
dam. He specializes in teacher training and research on learning disabili-
ties and reading development. He has served on state advocacy
committees, one of which created the publication "1 Can Learn,"a hand-
book for parents, teachers, and students. His work is a unique balance
between theory and practical application.
Tonight's lecture will focus on an overview of poor readers found in
our schools. Our speaker will discuss the differences related to poor
reader's information processing and also review applications for effec-
tive teaching. It is my privilege to introduce Dr. Michael Spagna.

Dr. Michael Spagna

I have been asked to talk tonight about poor readers and the differences
that exist, if any, between what Stanovich (1990) has termed "garden-vari-
ety" poor readers and children who have been identified as having "dys-
!exia." I wanted to begin by asking whether or not anyone had the
opportunity to read an article that appeared in the New York Times sever-
al weeks ago that reported research findings that suggest that dyslexia is
not a life-long phenomenon, as previously thought. I brought the article
with me tonight for those who didn't get a chance to see it.
I bring this article to your attention because it represents the type of
controversy that I will address tonight; namely, does the phenomenon of
"dyslexia" truly exist? How do individuals with dyslexia differ from non-
dyslexic poor readers in terms of cognitive functioning and reading per-
formance? And finally, if dyslexia does exist, is it curable?
In order to provide answers to these questions, it is necessary to start
at the beginning: an explanation of the historical roots of the field of
learning disabilities (hereafter, LD); a definition of the term "dyslexia"; a
presentation of results from "garden-variety"/dyslexic poor reader corn-
 All Poor Readers Are Not Dyslexic 89

parison studies; and, a discussion of implications for teachers and par-

ents regarding the instruction of dyslexic and non-dyslexic poor readers.

HISTORICAL ROOTS OF THE FIELD OF LEARNING DISABILITIES

AND THE STUDY OF DYSLEXIA

Let us begin with a diagram depicting the origins of the LD field. As shown
in Figure 1, the LD field and the study of dyslexia can be traced back to the
work of two physicians named Hinshelwood and Orton. Figure 1 shows
the chronological development of the study of LD and dyslexia, beginning
in the 1800's.
At this point, I would like to trace the four chronological phases re-
search in LD and dyslexia followed. Also, I want to talk about where dys-
lexia fits in with other types of learning disabilities such as dysgraphia,
developmental aphasia, and dyscalculia.
Over the years, I have been asked the following question by teachers
and parents alike: "Is dyslexia a unique phenomenon separate from learn-
ing disabilities?' Figure 1 should help answer this question.
Along the vertical axis of the diagram presented in Figure 1, one finds
the four chronological phases of research in learning disabilities: 1) the
Foundation Phase; 2) the Transition Phase; 3) the Integration Phase; and,
4) the Contemporary Phase. These phases took place from the 1800's
through the 1930's, the 1930's through the 1960's, the 1960's through
the 1 980's, and the 1980's through the present, respectively. Along the
horizontal axis, one notices different types of learning disabilities: Disor-
ders of Spoken Language; Disorders of Written Language; and, Disor-
ders of Perceptual and Motor Processes.
It is important to point out that one type of learning disability is con-
spicuously absent from Figure 1: Disorders of Mathematical Reasoning.
Some of you might be familiar with the term "dyscalculia," which is often
associated with this type of learning disability. Disorders of mathemati-
cal reasoning are distinct from problems with reading or writing that af-
fect math performance, and have just recently been studied closely.
The area that I am going to focus on tonight is located in the middle
section of Figure 1: Disorders of Written Language. This type of learning
disability is referred to today as the phenomenon of dyslexia. In the early
1900's, Hinshelwood and Orton were among the first to document chil-
dren coming into their clinic who were experiencing extreme difficulty
reading. These patients could not read fluently in spite of receiving nor-
mal instruction, coming from an average socio-cultural background, and
90 Michael E. Spagna

E
0
-c

-c

-Q

-c
0 C
C C
C
E
0•
0
-C -c
0 0 0
U, E—
bO -c
-c
ObO
I C

x
>-
-C
0
>-
-c
0
-c
0
0
-c
.C -c
0
ot
0
0
C
b) 0
b -c

£ •C
b) b) U
0.
c0.
C C
bQ) C
c .2
c0
EE
-5
.9
aJ
.9
-c
c t
c
.2
.
0.
E
a
--
>b
L F .2 U
—

U. .Z
0
 All Poor Readers Are Not Dyslexic

possessing average or above average cognitive functioning. At this time,

following the example of Hinshelwood and Orton, there manuscript
page were numerous case studies documenting the reading behaviors
exhibited by children.
As I discuss the history of dyslexia, it is very important to emphasize
the value of this initial case study research. As you will see later, research-
ers soon got away from these types of qualitative studies, instead opting
for larger, seemingly more glamorous, quantitative projects. This initial
work was invaluable since it was studied what children were doing while
engaged in reading. Only by observing dyslexic children as they read can
one determine whether their reading skills are qualitatively different
from other types of readers.
During the Foundation Phase, Hinshelwood (1917) was among the
first to publish observations, describing a thirteen year old male who was
able to learn auditorially but could not remember visual symbols. Hin-
shelwood speculated that this "word blindness" was due to a neurologi-
cal defect in the angular gyrus of the brain. Orton (1928) was famous for
coining the term, trephosymbo!ia," which directly translates to "twisted
symbols." Like Hinsheiwood, Orton reported cases of children who had
"word blindness," able to learn oral language but unable to decode
words. Orton theorized that this inability to read was not due to a brain
defect but attributable to a lack of cerebral dominance.
During the Foundation Phase, and into the early 1930's, this phenom-
enon of dyslexia was primarily studied from a medical perspective; and,
as a result, was generally believed to be a biological phenomenon,
caused by neurological dysfunction. From the 1 930's onward, however,
professionals outside the field of medicine, primarily in the disciplines of
psychology and education, became involved with the study of dyslexia.
During this Transition Phase, psychologists such as Mable Fernald (1943)
gained notoriety by studying the psychological characteristics of chil-
dren who were having difficulties reading. In fact, Fernald, through her
work at the University of California at Los Angeles (UCLA), was among
the first to propose that dyslexia was the result of specific psychological
abilities/processes which were dysfunctional—not operating at a level
commensurate to the level of other psychological processes. Although
her theory was proposed over seventy years ago, Fernald's notion of
faulty information processing is in accordance with modern theories
concerning dyslexia. Through work at her UCLA clinic, she developed a
multi-sensory approach, called the "VAKT" approach (Visual, Auditory,
Kinesthetic, and Tactile), to remediate reading and spelling difficulties.
92 Michael E. Spagna

Fernald's VAKT method was ultimately designed to help youngsters com-

pensate for an informational processing deficit. If you haven't had the
chance to read her book, Remedial Techniques in Basic School Objec-
tives (1943), I highly recommend it.
Turning now to the Integration Phase, the term "learning disabilities"
was first introduced by Samuel Kirk in 1963 to what was to become the
Association of Children with Learning Disabilities (ACLD). At this time, all
of a sudden, case studies on dyslexia disappeared from the research
landscape. With the introduction of the term "learning disabilities" in
1963, federal legislation soon followed in 1969 (Public Law 91—230) and
1975 (Public Law 94—142). With federal regulations used to determine
LD eligibility on the books, a rapid expansion of school programs de-
signed to educate children identified as having dyslexia was experienced
in the United States. For the first time, learning disabilities (and dyslexia)
was recognized as a disability category, deserving of special education
and related services.
As mentioned earlier, the first federal law was enacted in 1969, the
Children with Specific Learning Disabilities Act, otherwise known as Pub-
lic Law 91 —230. When P.L. 91 —230 was enacted, large numbers of
youngsters were identified as having learning disabilities, and pertinent
educational services were allocated. This legislation proved important
from an educational standpoint; children with dyslexia were finally given
access to necessary instructional interventions.
Finally, in the Contemporary Phase (1980's — present), the LD field has
continued to expand with services being extended to dyslexic adults,
mainstreaming and collaboration becoming the educational method of
choice, and the development of LD and dyslexia organizations and advo-
cacy groups.

THE IMPORTANCE OF CASE STUDY RESEARCH

I have started out this session tonight with a discussion of the historical
roots of the LD field and dyslexia for a reason: To point out that, with the
expansion of school programs during the Integration Phase, case study re-
search was largely abandoned, remaining unfinished. Without such quali-
tative research, the description of characteristics of dyslexic children was
left incomplete. In response to such abandonment of qualitative research,
one researcher, Sabatino (1981), said that the field of learning disabilities
had become a field of "service delivery in search of theory."
Actually, today, we see a re-emergence of case study research, with
 All Poor Readers Are Not Dyslexic 93

professionals returning to unfinished business, explaining how young-

sters with dyslexia read, and whether they read differently from other
poor readers. My own research follows in this line of inquiry, studying
the differences between children who are dyslexic and children who are
just "garden-variety" poor readers.
Before I leave this discussion of the importance of case study research,
let me mention the influential work of Elena Boder (1973) which remains
largely overlooked today. Boder is a child psychiatrist here in Los Angeles
who looked at the reading performance of children who had been identi-
fied as dyslexic, and purportedly discovered three types of dyslexia. I
shall return to Boder's three types of dyslexia later when I talk about im-
plications for instruction, because I believe the investigation of reading
differences provide insight into what goes on with youngsters who are
poor whole-word readers, versus children who are poor decoders.

BODER AND DYSLEXIA SUB-TYPES

Boder identified the following dyslexia sub-types: 1) "Dysphonetic" dys-

lexia; 2) "Dyseidetic" dyslexia; and, 3) a "Mixed" group. "dysphonetic"
dyslexia (67% of total dyslexics studied) were described as those children
who exhibited a lack of "phonological awareness," with the letters we see
on a page, "graphemes." Other researchers have referred to these readers
as having "deep dyslexia" (Coltheart, Patterson, & Marshall, 1980). Let me
give you an example of an error this type of reader might make: Seeing
the word "cape," and pronouncing it as "cap," failing to recognize the si-
lent "e." Boder explained that these readers usually substitute a whole
word that they are familiar with for an unfamiliar word that is difficult to
decode. A second type of dyslexic reader Boder reported, though not in
as great numbers, was termed a "Dyseidetic" reader (10% of total dyslex-
ics studied). Later, researchers referred to this group of readers as exhibit-
ing "surface dyslexia" (Coltheart et al., 1980). These youngsters were
described as being unable to read sight words effectively. However, they
could pronounce and read words that required "phonological awareness."
For example, these children, when exposed to the word "steak" (pro-
nounced correctly as "stak," would pronounce it as "stek." Boder pro-
vided the following explanation of this phenomenon: "Dyseidetic"
dyslexics are aware of the phonological rule that "ea" can be pronounced
as "e" in certain words and, therefore, have applied the rule in this
instance. In other words, these readers have difficulty with sight words,
which require previous exposure and visual memorization.
94 Michael E. Spagna

Finally, the third type of dyslexia described by Boder was the "Mixed"
group (23% of total dyslexics studied). These children not only exhibited
a poor sight vocabulary, but also experienced problems sounding out
words. As a result of the severity of reading problems in these young-
sters, Boder also offered the worst educational prognosis for this group:
"Mixed" group dyslexic children could not rely on sight-word or phonic
skills to compensate for word recognition/decoding weaknesses.
Before I leave Boder's work, which I think is very important, I want to
point out some additional findings that were reported after Boder's ini-
tial research. This research posed the question: "How would children
from the three dyslexia groups read irregular words?" An example of an
irregular word would be the word "laugh" which is a sight word that can-
not be decoded using "regular" rules of phonics. If one tries to sound out
"laugh" using only phonological skills, one might pronounce it as "lag,"
interpreting the graphemes "gh" as making the "g" sound/phoneme. Ac-
cording to Boder's work, what might one expect regarding the perfor-
mance of "Dysphonetic" and "Dyseidetic" dyslexic readers when
exposed to sight words such as "laugh?" In other words, which type of
dyslexic reader would be expected to have more difficulty reading sight
words?
If you said the "Dyseidetic" group, you would be correct since these
youngsters would, most likely, experience difficulty remembering the
pronunciation of the word as a whole unit. Instead, Dyseidetic" readers
attempt to sound out unfamiliar words—relying on phonics, which pro-
duce incorrect pronunciations such as "lag." The "Dysphonetic" group,
on the other hand, could probably read "laugh" correctly, especially if
they had been previously exposed to it. Remember that in the "Dyspho-
netic" group, the knowledge of sight words is stronger than the ability to
sound out words.
Let me give you another example which I think will sharpen the dis-
crimination between "Dysphonetic" and "Dyseidetic" dyslexics. "Pseu-
do-words" or "nonsense" words are words that are fairly regular,
phonetically speaking. Usually, a "real" word is changed slightly to create
a new "nonsense" word; for instance, if I take the word "jump," remove
the first letter "j" and replace it with a "," I have created the "nonsense"
word "tump." If one were to construct a list of these "nonsense" words
and present it to the three groups of dyslexic youngsters described by
Boder, which group would you expect to have more difficulty reading
these "nonsense" words? The "Dysphonetic" or the "Dyseidetic" group?
Using Boder's findings, and according to her theory, "Dysphonetic"
 All Poor Readers Are Not Dyslexic 95

dyslexics should have more difficulty reading "nonsense" words, since

they lack strong phonological skills.
Boder's work should be acknowledged as a significant contribution to
the study of dyslexia since it provided considerable insight into how chil-
dren read. To finish with Figure 1, research conducted during the Con-
temporary Phase will most likely pose "why" questions instead of "how"
questions, not just investigating "how" youngsters read sight words and
"nonsense" words ala Boder, but also examining "why" children read
words in the manner that they do. Obviously, some children won't be
able to verbalize what they're doing when reading words; but others
can. And I shall describe later, in my own research, what children have
told me when asked "why" they pronounce words in a certain manner.

INCIDENCE AND A DEFINITION OF DYSLEXIA

Before continuing with my talk tonight, let me define the term "dyslexia"
for you according to the World Federation of Neurology (cited in Shay-
witz, Escobar, Shaywitz, Fletcher, & Makuch, 1992): "a disorder mani-
fested by failure to attain the language skills of reading, writing and spelling,
despite conventional instruction, adequate intelligence and socio-cultural
opportunity."
Now, to turn to present day information about dyslexia, I would like to
discuss the incidence of children with dyslexia in California and the
United States. Due to Public Law 91—230, as well as ensuing legislation
(P.L. 94-142 and Section 504 of the Rehabilitation Act of 1973), there
has been an explosion in the number of youngsters identified as having
disabilities. Currently, in the state of California, approximately 5% of the
school-age population has been identified as having LD (USOSERS,
1991). This represents approximately a 140% increase since 1975 in the
number of children identified as LD. Faced with this information, howev-
er, one must ask: "Of those identified as LD, how many youngsters are
poor readers, and possibly dyslexic?" In studies of school-age children,
between 2% and 6% are usually found to have dyslexia (Yule & Rutter,
1975). Applying these findings to the figures reported earlier, it could be
argued that anywhere between 40% and 100% of the LD population has
dyslexia.
Also, when confronted with such a staggering increase in the number
of LD-identified children, one must also ask: "Are all those identified as
LD, truly LD?" One study that addresses this issue was conducted by She-
pard, Smith & Vojir (1983) in Colorado. Shepard et al.'s findings appear
96 Michael E. Spagna

in Figure 2. Shepard et al. attempted to determine whether or not chil-

dren who were being labelled learning disabled truly were, using psycho-
metric data collected at various school sites. You'll notice in Figure 2,
under the learning disabilities category, that Shepard et al. found less
than 50% of the population studied, using Colorado identification crite-
ria, were truly learning disabled. Many children identified as LD should
have properly been diagnosed in one of the other categories listed in Fig-
ure 2: Other Handicaps; Other Learning Problems; or, Other.
I don't have time tonight to talk about the reasons for this, but, suffice
to say that teachers and administrators are faced with a very hard deci-
sion: "I have these students who do not meet the criteria exactly but
they're not making it in my class/school." "What am I going to do?" Sim-
ply put, many youngsters are identified as LD because this is an avenue
to provide educational assistance; without the label, teachers and admin-
istrators are faced with the very real alternative—early drop-out. Faced
with such a decision, Shepard's findings appear less surprising. However,
with the possibility for a greater number of "false-positive" LD identifica-
tions—children who are not LD being identified as LD—educators and re-
searchers are, in turn, faced with an equally difficult proposition:
studying a heterogeneous population which might contain less than
50% "true" LD children. Obviously, the implications for research and
education are enormous.
Now, let's talk about incidence studies of dyslexia. Reported in the lit-
erature, there was a landmark study, conducted in England by Rutter and
Yule (1975), known as the "Isle of Wight Study." These researchers tested
approximately thirty-four hundred 9, 10 and 1 1-year-olds to study their
reading skills, cognitive functioning, and so forth. Rutter and Yule re-
ported that certain youngsters exhibited high levels of general cognitive
functioning but comparatively lower levels of reading skill. These chil-
dren as children were referred to by Rutter and Yule as having "Specific
Reading Retardation" (hereafter, SRR). Moreover, Rutter and Yule differ-
entiated these youngsters from children who were not only poor readers
but also demonstrated lower levels of cognitive functioning; this second
group of poor readers was identified as having "General Reading Back-
wardness" (hereafter, GRB).
This 1975 study is important because Rutter and Yule were among the
first researchers to discriminate between two groups of poor readers:
SRR children with high-level cognitive functioning who were poor read-
ers (we normally consider this group to be dyslexic poor readers), and
GRB youngsters who had low cognitive functioning across the board, in-
 All Poor Readers Are Not Dyslexic 97

Percentage of Standard Error

LD Cases

Other Handicaps
Educable Mentally Retarded 2.6 +0.6

Emotionally Disturbed 7.5 +1.0

Hearing Handicapped 0.2 +0.2

(Total) 10.3

Learning Disabilities
Significant Ability/Achievement Discrepancy 20.5 +2.0

High Quality Processing Deficit 4.7 +0.8

Brain Injured 0.6 +0.3

Hyperactive 2.0 +0.6

Weak Significant Discrepancy and Verbal/ 3.6 +0.6

Performance Discrepancy
Weak Significant Discrepancy and Medium 1.1 +0.4
Quality Processing Discrepancy
Medium Quality Processing Discrepancy and 6.6 +1.2
Verbal/Performance Discrepancy
Medium Quality Processing Discrepancy 3.5 +0.8

(Total) 42.6
Other Learning Problems
Language Interference 6.6 +1.0
Slow Learners 11.4 +1.4

Environmental Causes 2.2 +0.6

Below Grade Level Achievement 6.1 +1.0

Minor Behavioral Problems 3.7 +0.8

(Total) 30.0

Other
Poor Assessment (no IQ and no Ach. tests) 6.4 +1.3

Miscellaneous (including normal) 10.6 +1.3

(Total) 17.0

Figure 2. Identification of learning-problem subgroups in the Colorado Study (Shepard,

Smith, & Vojir, 1983).
98 Michael E. Spagna

Figure 3. Normal distribution of reading ability among the school-age poulation.

cluding lower reading ability (we normally consider this group to be "gar-
den-variety" poor readers). Of course, the insinuation with SRR children
is that something's gone wrong since a relatively high level of cognitive
functioning exists. Why aren't SRR children reading up to their ability? It
is not surprising that the child with low levels of cognitive functioning
also exhibits low level reading skills.
I bring this study to your attention for the following reason: When Rut-
ter and Yule presented their findings, quite a bit of controversy was gen-
erated. It had previously been thought that only one group—not two—of
poor readers existed, the GRB group.
To further understand the importance of Rutter and Yule's study, I shall
describe their methodology in more detail. Rutter and Yule examined all
of the Isle of Wight youngsters who had a certain IQ level and looked to
see how they were distributed in terms of their reading ability. Looking at
a normal curve, such as the one presented in Figure 3, one would expect
all of the children having the same level of intelligence to exhibit a read-
ing ability distribution similar to a normal curve. It is important to notice
that the shaded area appearing in Figure 3 represents a group of children
who were found to have reading skills "two standard deviations below
the mean." In other words, these youngsters have significantly below av-
erage reading skills. If one were to think that the reading skills of children
 All Poor Readers Are Not Dyslexic 99

Figure 4. Bi-modal distribution of reading ability reported by Rutter and Yule.

of similar IQ were distributed along a normal curve, one should also ex-
pect that only 2.28% of this same population of youngsters would have
severe reading problems "two standard deviations below the mean."
When Rutter and Yule conducted their research, they discovered a
greater incidence of children with severe reading problems than would
be expected using hypothetical distribution of reading skifl depicted in
Figure 3. Indeed, Rutter and Yule found that approximately 9% of the Isle
of Wight population exhibited severe reading problems—not the 2.28$
expected. Instead of a normal distribution, Rutter and Yule reported that
reading skills could better be described as comprising a bimodal distribu-
tion, with a smaller crest appearing towards the bottom of the curve. This
bimodal distribution is depicted in Figure 4.
The conclusion offered by Rutter and Yule—namely, that reading per-
formance was not evenly distributed among youngsters of similar
IQ—was revolutionary at the time. Pointing to these findings, researchers
all over the world believed that the "Holy Grail" of dyslexia had finally
been discovered, proving that a larger group of children—comprised par-
tially of dyslexic individuals—were experiencing reading problems than
would be expected. In several professional circles, this finding validated
the long-held belief that a "true" phenomenon of dyslexia existed. Fur-
thermore, Rutter and Yule's work was interpreted to indicate that these
dyslexic poor readers were distinct from general poor readers.
Several researchers have disputed Rutter and Yule's findings, however
(most notably, Rodgers, 1983). If we return to Figure 4 for a moment, I
will explain why Rutter and Yule's findings and, hence, their conclusions
have purportedly failed to hold up under scrutiny.
100 Michael E. Spagna

Figure 5. Normal distribution of reading ability alter removing ceiling effects (Rodgers,
1983).

You will notice that the curve presented in Figure 4, when compared
to the curve shown in Figure 3, is skewed to the right. One possible rea-
son for the skew would be that the test was too easy; in other words, the
majority of children taking the test scored well on the assessment instru-
ment. Educational measurement experts refer to this phenomenon as a
"ceiling effect" with many subjects scoring manuscript toward the upper
limit of the test. When "ceiling effects" are present, it can be inferred that
the measurement device used fails to maximally discriminate between
the performance of subjects.
Applying an understanding of this phenomenon to Rutter and Yule's
findings, one can justifiably offer a competing interpretation of the signif-
icance of a bimodal distribution: Rutter and Yule's study was method-
ologically flawed; they failed to use a more appropriate measurement
device, one that guards against "ceiling effects." Rodgers (1983) went
back and reanalyzed the finding of Rutter and Yule, controlling for "ceil-
ing effects" on the reading skill measurement device. A new distribution
of reading scores was generated by Rodgers which is presented in Figure
5. As you can see in Figure 5, once "ceiling effects" are removed from
the data, a normal, not a skewed curve results. This finding directly con-
tradicts those presented by Rutter and Yule, in effect, pointing away from
the conclusion that an unexpected dyslexic group of poor readers exists.
So, again, one witnesses another controversy being created, with people
doubting the existence of dyslexia.
According to Rodgers' work, one could conclude that there is no such
 All Poor Readers Are Not Dyslexic 101

phenomenon as dyslexia, especially since Figure 5 doesn't portray an un-

expected abnormal group of poor readers at the bottom of the distribu-
tion.
As a result of Rodgers' study, the findings reported by Rutter and Yule
are pretty much discounted by professionals in the field. This is quite un-
fortunate, since Rutter and Yule gathered additional information in their
longitudinal study that is valuable.
After an initial examination of the cognitive and reading performance
of the "Isle of Wight" population, Rutter and Yule re-administered all
tests five years later. Based on this longitudinal information, Rutter and
Yule offered an educational prognosis for the SRR and GRB groups: five
years later, SRR youngsters continued to experience difficulty with their
reading (even lower performance than their GRB counterparts), but also
exhibited mathematics skills approaching grade level expectations; GRB
children, on the other hand, scored well below grade level on the follow-
up tests of reading and mathematics.
These additional follow-up findings prove important to educators, and,
to a certain extent, are more significant than the previously discussed in-
cidence findings; comparing the performance of SRR and GRB children,
the two groups have different educational prognoses, with SRR young-
sters requiring more intensive instruction in reading although remaining
at grade-level in other academic areas (mathematics).

"PHONECIAN" AND "CHINESE" READERS:

A TWO-DIMENSIONAL CONTINUUM OF READING SKILLS

For the last seventeen years, thanks to the work of Rutter and Yule, re-
searchers investigated the reading performance of children, searching for
ways to discriminate between types of readers. Baron and Strawson
(1976) were among the first to describe '"'normal" readers as belonging to
one of two groups: "Phonecians" and "Chinese" readers. To be more spe-
cific, Baron and Strawson described Phonecian readers as being better al-
phabetic readers, using a "sounding-out" approach to decode words;
hence, this group of readers could be characterized as having a relatively
high level of phonological awareness. Chinese readers, on the other hand,
were characterized as being good sight-readers, recognizing words visual-
ly as single units having a unique pronunciation. Another way of describ-
ing these two groups of readers would be to characterize "Phonecian"
readers as relying on an "orthographic system" to decode words, using
knowledge of phoneme/grapheme correspondences while reading; "Chi-
102 Michael E. Spagna

PHONIC
READING

GOOD

WHOLE
WORD
READING

POOR GOOD

POOR

Figure 6. A two-dimensional continuum of reading skills (Ellis, 1985).

nese" readers, in comparison, would be described as relying on a "logo-

gaphic system" to read, using visual-memory to access pronunciations of
words as whole units. Figure 6 (Ellis, 1985) illustrates reading skills using a
two-dimensional chart; the vertical axis represents "phonic reading" skill
(sounding out approach) and the horizontal axis represents "whole word
reading" skill (sight-word approach). The top of the vertical axis represents
good "Phonic reading" skill; the bottom of the vertical axis indicates poor
"phonic reading" skill. To complete the diagram, the left side of the hori-
zontal axis represents poor "whole word reading" skill, while the right side
of the horizontal axis indicates good "whole word reading" skill. Is there
anyone in the audience tonight who can guess where Baron and Straw-
son's "Chinese" readers would exist on this diagram? Looking for a mo-
ment at Figure 7, you will notice that this group can be found in the
 All Poor Readers Are Not Dyslexic 103

PHONIC
READING
PHONECIANS GOOD READERS
GOOD

WHOLE
WORD
READING

POOR GOOD

DYSEIDETIC DYSLEXICS
O0

CHINESE

POOR
MIXED DYSLEXICS DYSPHONETIC
DYSLEXICS

Figure 7. Hypothetical distribution of average, good, Chinese, Phoecian, and dyslexic

readers; homogeneous continuum (Ellis, 1985).

middle-left part of the graph. The "Chinese" readers belong here since
they exhibit good whole word reading skill, but only average phonic read-
ing skill.
Returning again to Figure 7, where do you think the "Phonecian" read-
ing group belongs? Remember that this reader group has good phonic
reading skills but not necessarily good whole word reading skills. Accord-
ing to Baron and Strawson's work, this reader group would be best
placed in the upper-middle to upper-left portion of the diagram.
Now, finally, where would you put the students who are dys'exic read-
ers, "Dysphonetic," "Dyseidetic" or "Mixed" groups. As Figure 7 depicts,
104 Michael E. Spagna

"Dysphonetic" readers—who have poor phonic reading skills but average

whole word reading skills—are placed at the lower-middle part of the dia-
gram. "Dyseidetic" dyslexics, on the other hand, appear at the middle-
left section of the figure since these readers exhibit poor whole word
reading skills and average phonic reading skills. The third group of dyslex-
ic readers, the "Mixed" group, appears at the lower-left part of the graph;
this group exhibits poor phonic reading skills as well as poor whole word
reading skills.
To complete the diagram presented in Figure 7, notice that "Good"
readers appear in the upper-right section of the graph since they have
good phonic and whole word reading skills. It is important to point out
here that terms like "Dysphonetic" dyslexics, "Dyseidetic" dyslexics,
"Chinese" readers, and "Phonecian" readers, one might be left with the
impression that each term identifies separate, distinct groups of readers,
with little or no overlap between members of the different groups. Cur-
rent thinking (see Ellis, 1985) dictates that good and poor readers do not
fall into separate, homogeneous groups, such as those depicted in Figure
7. Instead, reader groups are distributed in a fashion similar to that de-
picted in Figure 8; children fall along a heterogeneous continuum, with
quite a lot of overlap between different skill levels.
Figure 8 clearly illustrates how children differ from one another in their
reading skills, using the two axes of phonic reading and whole word
reading to create a reading-skill continuum. Experts in the field, for the
most part, agree that all readers belong in one of the Figure 8 reading
skills quadrants. Some youngsters are not going to be great sight-word
readers; others are going to experience difficulty sounding out words.
But, by using both of these dimensions, you can kind of get a picture of
where children might fall along this continuum.

DYSLEXIC VS. "GARDEN-VARIETY" POOR READER

COMPARISON STUDIES

Several studies have been conducted, examining the reading performance

of children who would appear in the lower-left hand section of Figure 8,
but not belonging to the dyslexia categories. These non-dyslexic young-
sters have been identified as "Garden-variety" poor readers (Stanovich,
1 990). Similar to the youngsters identified by Rutter and Yule as belonging
to the "General Reading Backwardness" (GRB) group, the "Garden-vari-
ety" group exhibits below average cognitive functioning and below aver-
age reading skills. For the most part, studies examining the performance of
 All Poor Readers Are Not Dyslexic 105

PHONIC
READING
PHONECIANS GOOD READERS

o
0
o
.
0 GOOD

0 0 0
0
C)

0
0 0
00
C) 0
000
" C.) 0 •. C)
t. WHOLE
_ AVERAGE
READERS 0'' WORD
READING

POOR 0 . 0 'o
0 00 0 GOOD

DYSEIDETIC DYSLEXCS () çQ ( C.
C.) 0¼J .Q C.
0 0 o
C)
...,.

C 0 CHINESE

0 0
POOR
MIXED DYSLEXICS DYSPHONETIC
DYSLEXICS

Figure 8. Hypothetical distribution of average, good, Chinese, Phoecian, and dyslexic

readers; heterogeneous continuum (Ellis, 1985).

this "Garden-variety" group have compared these youngsters to children

who have been identified as having some form of dyslexia or "specific
reading retardation" (children who have average or above average cogni-
tive functioning but below average reading skills). Two such studies, one
conducted at the University of Kansas (Warner, Schumaker, Alley, & Des-
hler, 1980) and one at the University of Minnesota (Ysseldyke, Algozzine,
Shinn, & McGue, (1982), compared the cognitive functioning and reading
performance of dyslexic poor readers and "Garden-variety" poor readers.
Considering the information I have presented so far about youngsters
who would be classified as either dyslexic or "Garden-variety" poor read-
ers, what would you speculate were the findings of these studies? In oth-
106 Michael E. Spagna

er words, what do you think the two research groups found when
comparing the cognitive functioning and reading skills of the two
groups?
Based on the identification criteria already set out, one would expect
both groups to exhibit below average reading skills; one would also ex-
pect the dyslexic group to have higher levels of cognitive functioning
when compared to the "Garden-variety" group. When reviewing the re-
sults obtained from the Kansas and Minnesota studies, however, one is
faced with quite unexpected findings.
First of all, both research groups failed to report significant cognitive
functioning differences between the two groups. However, the dyslexic
group scored at a lower level than the "Garden-variety" group on reading
tests. In other words, one might interpret these findings to indicate that
the children who were identified as having dyslexia were, simply put, the
poorest of the poor readers. Do these findings make sense considering
our seemingly incorrect predictions? Why were the results opposite from
what we predicted would happen? A closer look at the University of Kan-
sas and the University of Minnesota studies reveals the answers to these
questions.
Neither study selected youngsters using criteria similar to that de-
scribed earlier in Rutter and Yule's work; namely, discriminating between
dyslexic and "Garden-variety" poor readers using differences in cogni-
tive functioning to separate the two groups. Instead, the University of
Kansas and University of Minnesota studies relied upon school-based
identification criteria to separate dyslexic and non-dyslexic poor readers.
So, a better interpretation of the findings reported in the Kansas and Min-
nesota studies would be the following: The school sites sampled identi-
fied children experiencing the most difficulty reading as having dyslexia,
without regard to differing levels of cognitive functioning. It is important
to point out that schools, faced with dwindling financial resources, might
identify those children who require the greatest educational intervention
as having "dyslexia." Such a decision would obviously by influenced by
economic concerns first and foremost.
Any of you who have ever worked with dyslexic youngsters, however,
have come to find that differences do exist between these children and
"Garden-variety" poor readers. Simply describing children with dyslexia
as the poorest of the poor readers is an inaccurate statements. If intel-
lectual differences did not exist, then one would expect that a dyslexic
youngster would exhibit cognitive functioning commensurate with his!
her level of reading skill—below average in both areas.
 All Poor Readers Are Not Dyslexic 107

My experience with dyslexic children, however, fails to support this

predicted level of performance: Dyslexic readers have a rich knowledge
of the world, what's going on around them; they can extract information
and exhibit average to above average levels of cognitive functioning.
Instead of demonstrating generalized deficits in such cognitive areas as
memory, linguistic comprehension, etc., dyslexic individuals experience
a specific type of learning problem either in their understanding of pho-
nics or in their ability to remember whole word units. "Garden-variety"
poor readers, in comparison, do experience generalized cognitive defi-
cits that not only affect memory and linguistic skills, but which also affect
reading skills.
Differences in cognitive functioning between dyslexic and "Garden-va-
riety" poor readers will directly influence the effectiveness of education-
al interventions: A student with low cognitive functioning and low
reading skills will require educational experiences that will build his/her
knowledge of the world; with a dyslexic student, however, it is more im-
portant to tap into existing knowledge of the world, using his/her experi-
ential background to make reading more meaningful. This is not to say
that "garden-variety" poor readers do not possess significant knowledge
of the world around them; they do. But it is also important to emphasize
that dyslexic youngsters, as described earlier, are more likely to have ac-
quired even more knowledge than their "Garden-variety" counterparts.
The secret to teaching reading to both groups is to unlock the seemingly
hidden background knowledge that these youngsters possess and to
demonstrate how new knowledge, gained through reading, can be
linked to what they already know.

A "Simple" Model of Reading

In order to understand how dyslexic and non-dyslexic poor readers might
differ in their reading skills, I think it's helpful to show you an equation,
proposed by Gough and Tunmer (1986), that describes the relation be-
tween decoding words—a source of extreme frustration to dyslexic read-
ers—and reading. Essentially, Cough and Tunmer believed that reading
comprehension (R) is the product of decoding (D) and linguistic compre-
hension (C); hence, the equation: R = D x C. by linguistic comprehension,
Cough and Tunmer refer to the individual's understanding of language,
and the world around him/her.
Using this reading equation, with each variable ranging from 0 (lowest
skill level) to 1 (highest skill level), Cough and Tunmer proceed to de-
scribe the different types of readers encountered among the school-age
108 Michael E. Spagna

population: "Normal" readers; "Dyslexic" readers; "Hyperlexic" readers;

and "Garden-variety" poor readers. A "Normal" reader would be charac-
terized as having a high level of decoding (1.0) and linguistic comprehen-
sion (1.0). The predicted reading comprehension of this "Normal" reader
would be equal to the product of these two components; hence, 1.0 (de-
coding) x 1.0 (linguistic comprehension) = 1.0 (reading comprehension).
In comparison, a Dyslexic reader would be expected to exhibit poor
decoding skill; let's say, for illustrative purposes, that a dyslexic reader
has a decoding level of 0.40, less than half of that exhibited by normal
readers. The dyslexic person's linguistic comprehension, his/her knowl-
edge of the world and what he/she can pick up in conversation however,
compared to normal readers, is nearly identical: linguistic comprehen-
sion equals 0.9. Multiplying those two variables, one arrives at a substan-
dard reading comprehension level: 0.36—significantly below a perfect
score of 1.0
"Garden-variety" poor readers, in comparison to dyslexic readers, are
characterized by Gough and Tunmer as having relatively higher levels of
decoding skill—say 0.60—and lower levels of linguistic comprehen-
sion—say, 0.60. According to the reading equation, one would predict
that the reading comprehension of "Garden-variety" poor read-
ers—0.36—would be equal to that of Dyslexic readers.
Finally, Gough and Tunmer describe a fourth type of reader, the Hy-
perlexic reader. This type of reader is characterized as having relatively
high levels of decoding skill (e.g., Decoding equal to 0.90) and low levels
of linguistic comprehension (e.g., Linguistic comprehension equal to
0.40). Usually, the kind of individuals we see who have hyperlexia are
children having moderate to severe brain damage: children who have
had some kind of neurological insult or people who have had strokes,
maintaining some of their decoding ability but losing general language
skills. Using Gough and Tunmer's equation, one would predict that a Hy-
perlexic reader would exhibit a reading comprehension level of 0.36,
identical to the levels found for "Dyslexic" and "Garden-variety" poor
readers.
Considering the reading comprehension levels of the three groups of
poor readers—all at 0.36, respectively—it is necessary to discuss educa-
tional implications for these readers. Think about it—is it easier to build
up a child's understanding of the world, or is it easier to teach decoding
skills? If it were possible to remediate the decoding skill deficit of all three
poor reader types, changing decoding values to 1.0, which group would
exhibit the highest level of reading comprehension?
 All Poor Readers Are Not Dyslexic 109

Turning back one final time to the reading equation proposed by

Gough and Tunmer, we can see the new reading comprehension levels
of the three poor reader groups if the decoding variable is set at a perfect
value of 1 .0 for each group; previous reading comprehension levels will
be listed in parentheses.

"Dyslexic Readers": 1.0 (D) x 0.9 (C) = 0.9 (R) [0.36]

"Garden-variety" Poor Readers: 1.0 (D) x 0.6 (C) =0.6 (R) [0.361
"Hyperlexic" Readers: 1.0 (D) x 0.4 (C) = 0.4 (R) [0.36]
It becomes quite obvious that, if the equation proposed by Gough and
Tunmer proves valid, Dyslexic readers have the best prognosis for educa-
tional success, as far as improved reading is concerned once their decod-
ing deficits are remediated.

Decoding Strategies of "Dyslexic" and

"Garden-Variety" Poor Readers

So far I have been talking about theoretical models and "simple" equa-
tions to describe different types of readers. It all seems logical on paper
and in theory. But, how does one test these theories to ascertain their ve-
racity? If the theoretical reading continuum, presented in Figure 8, really
holds up, one should be able to interview and test youngsters to investi-
gate whether or not qualitative differences do exist between "dyslexic"
and "garden-variety" poor readers. Sticking to the theory, "garden—variety"
poor readers should have poor decoding skills as well as low levels of lin-
guistic comprehension; "dyslexic" readers, in comparison, should exhibit
similar decoding deficits, but should also have higher levels of linguistic
comprehension. In other words, "dyslexic" youngsters should be poor de-
coders and have a relatively good understanding of the real world.
In my research, I have investigated the decoding skills and linguistic
comprehension of "dyslexic" and "garden-variety" poor readers. There
were two phase to a project I began about a year and a half ago. The first
phase began with a meeting I was fortunate to have with Richard Wood-
cock, who created the Woodcock Reading Mastery Test. Woodcock af-
forded me access to his database of 6,000 people used to standardize
the Woodcock-Johnson Psycho-Educational Battery-Revised (1989). In
order to compare the reading performance of school-age youngsters, I
separated children into three groups: good readers, "dyslexic" poor read-
ers, and "garden-variety" poor readers. The research involved an ex-
amination of the performance of "dyslexic" and "garden-variety" poor
110 Michael E. Spagna

readers on one of the subtests of the Woodcock-Johnson Psycho-Educa-

tional Battery, the Word Attack subtest (a test of "nonsense" words). It is
believed that the best measure of phonological awareness involves "non-
sense" or pseudo-words; since these pseudo-words are unfamiliar to the
reader, he/she cannot rely on a sight-word approach and must decode
them using phonological knowledge. Boder's research (1973) has
shown that youngsters who can be classified as having "Dysphonetic dys-
lexia" will encounter difficulty reading such "nonsense" words aloud.
The Woodcock-Johnson Psycho-Educational Battery includes a list of
pseudo-words in the Word Attack subtest. Figure 9 lists all of the "non-
sense" words included in the Word Attack subtest; notice that the pseu-
do-words become increasingly difficult beginning with a simple
consonant-vowel-consonant (CVC) combination, "nat," and ending with
a more complex, three-syllable pseudo-word, "I'depnonle.l." Let me take
a moment to pronounce each of these pseudo-words for you as you fol-
low along with Figure 9, beginning with sample item A: /nat/, ib/, /tif/,
/hap/, /nan/, /mel/, /jaks/, /lek/, /then't/, /chur/, /fep/, /wus/,
/sham[b'l]/, /yash/, /mib[gus]/, /splaunch/, /sast/, /rouch/, /noink/,
/kwog/, /lin[di][fi]/, /wum/, /fi/, /hud[nedl/, /me[fret][sun]/, /siTh/,
/koj/, and /dep[non][lel].
Using the Word Attack subtest, I gathered information from 1 35
fourth, fifth, and sixth graders enrolled in public schools located in the
Bay Area of Northern California. As I mentioned earlier, all of the young-
sters were separated into three different reader categories: "good" read-
ers; "dyslexic" poor readers; and "garden-variety" poor readers. Each of
these reader groups was identified in the following manner: 1) "good"
readers—performance on a standardized scholastic reading test at or
above the 50th percentile; 2) "dyslexic" poor readers—performance on a
standardized scholastic reading test at or below the 25th percentile, and
identification as having a learning disability by a school-based student
study team; and 3) "garden-variety" poor readers—performance on a
standardized scholastic reading test at or below the 25th percentile, and
no identification as having a learning disability. Since a "discrepancy
method" between cognitive functioning and academic performance is
the most used criterion for learning disability identification in the United
States, it was assumed that "dyslexic" poor readers met this criterion
while "garden-variety" poor readers did not.
As expected, according to the equation offered by Gough and Tun-
mer, good readers were able to decode the majority of pseudo-word
items. The "dyslexic" poor readers and the "garden-variety" poor readers,
 All Poor Readers Are Not Dyslexic 111

Basel Item 1
Ceiling 5 consecutive failed

A _________ nat ADMINISTRATION

b ________ ib DIRECTIONS
1 ____________ tiff 'I want to read some words that are
2 _________ hap not real words. Tell me how they
sound."
3 _________ nan
4 ________ melI Point to 'nat.'
"How does this word sound?"
5 _________ jox
Point to 'ib' and say:
'How does this word sound?"
6 ________ leek
Proceed to item 1 for all subjects.
7 _________ then't 'Tell me how each of these words
8 _________ chur sound. Don't go too fast."
9 ________ feap Point to each word if necessary. If the
10 ________ wuss subject does not respond in a few se-
conds, encourage a response. If the
subject still does not respond, contin-
11 ________ shomble
ue the test y pointing to the next
12 ________ yosh word. Do not pronounce any words
13 ________ mibgus for the subject.
14 ________ splaunch
15 ________ saist

16 _________ wroutch
17 _______ knoink
18 _______ quog
19 _________ lindify
20 ________ whumb

21 phigh
22 _________ hudned
23 _________ maIreatsun
24 _________ cythe
25 ________ coge
26 ________ depnonlel

Figure 9. Above left, items from the Word Attack subtest of the Woodcock-Johnson Psy-
cho-Educational Battery, Part Two; right, administration directions for the Word Attack sub-
test.
112 Michael E. Spagna

in contrast, experienced difficulty with the subtest, mispronouricing a

significant portion of the "nonsense" words. At least at a quantitative lev-
el, no differences were noted in the performance of both poor reader
groups on the Word Attack subtest. A qualitative analysis of the errors
made, however, revealed important information regarding potential dif-
ferences in the way in which "dyslexic" and "garden-variety" poor read-
ers attempted to decode the pseudo-words.
In general, when faced with a new "nonsense" word, the "garden-vari-
ety" poor reader would attempt to apply the phonological knowledge
they possessed—albeit minimal compared to their "good" reader coun-
terparts—in an attempt to pronounce the unfamiliar words. For example:
Item #23, "mafreatsun," which is correctly pronounced /[me][fret][sun]/,
was pronounced as /[ma][ferts]/ by "garden-variety" poor readers. Essen-
tially, "garden-variety" poor readers would attempt to employ their de-
coding skill to read this "nonsense" word; but because of their
inadequate knowledge of phonics, "garden-variety" poor readers fail to
look at the entire word, leaving off endings—in this case the /[sun]/ in
"mafretsun." Also notice that the internal configuration of the pseudo-
word, "freat" has also been transposed by the "garden-variety" poor
reader, pronounced instead as "fert."
In comparison with the performance of the "garden-variety" poor
readers, which was predictable considering their inadequate knowledge
of phonics, "dyslexic" readers, surprisingly, pronounced several of the
pseudo-words in an entirely unexpected fashion. Since all of the items on
the Word Attack subtest are arranged in a hierarchical order, from easiest
to hardest, one would expect that both the "garden-variety" and the dys-
lexic" groups would reach a "ceiling of phonics competency" and begin
to mispronounce items consistently. This prediction held true for the
"garden-variety" group but not for the "dyslexic" group. Instead of reach-
ing a "ceiling," youngsters who had been identified as having dyslexia
made several unexpected correct responses beyond what would be con-
sidered their "true level" of performance based on their level of phono-
logical awareness.
Faced with the same "nonsense" word "mafreatsun" that was mispro-
nounced as "maferts" by the "garden-variety" poor readers, a dyslexic
reader used an entirely different strategy to decode the word: Unable to
properly decode the word using phonics exclusively, this youngster
employed a sight-word strategy, looking for familiar real words em-
bedded within the pseudo-word. This dyslexic youngster read "mafreat-
sun" in the following manner: He explained that the first part of the word
 All Poor Readers Are Not Dyslexic 113

looked like "Ma," the second part of the word looked like "treat" but
with an "f" instead of a "t," and the end of the word was like the "sun" in
the sky. With each of these parts of the "nonsense" word properly classi-
fied and recognized, this child was able to put all of the segments togeth-
er to properly pronounce the pseudo-word. This finding—that "dyslexic"
poor readers would employ a sight-word strategy in an attempt to recog-
nize real words embedded within a pseudo-word was a consistent one
repeated with several dyslexic readers. No "garden-variety" readers used
this approach to correctly pronounce unfamiliar "nonsense" words.
The finding that "dyslexic" poor readers might use alternate strategies
to decode unfamiliar words might have important ramifications for ap-
propriate educational interventions. If teachers could harness the dyslex-
ic youngster's knowledge of real words or linguistic comprehension,
children who have previously experienced frustration could now read
words correctly. With dyslexic readers, I also found that several students
also got some easier items wrong, whereas the low-achieving poor read-
ers got them right. To be more specific, I found that, when exposed to
Item #8 "chur," "garden-variety" poor readers would correctly pro-
nounce it, while dyslexic readers would see the word, become frustrated
that they couldn't sound it out, and attempt to recall a more familiar real
word such as "church." Another example of this phenomenon occurred
with Item #26 "depnonlel," the hardest of the items. Attempting to use
minimal phonics skills, "garden-variety" poor readers pronounced this
item as "depnony." Again, one notices that the ending of the "nonsense"
word has been left off characteristic of the errors this group of young-
sters made. They started to sound it out and never finished.
"Dyslexic" readers, on the other hand, unfamiliar with the pseudo-
word and unable to accurately apply phonics skills, incorporated the "d,"
"I," and "n" to pronounce the item as "dolphin." Again, "dyslexic" read-
ers were relying on their knowledge of real words to compensate for
their lack of phonics.
Even though it was clearly explained to all youngsters tested that the
Word Attack subtest was a list of new words, not real words, and this dis-
claimer was repeated during a second administration of the subtest, "dys-
lexic" readers continued to pronounce Item #26 as "dolphin."

Developmental Lags and Phonological-Core Deficits

One researcher has offered a possible explanation as to why this phenom-
enon occurs; namely, that "dyslexic" readers are able to tap into a richer
knowledge of linguistic comprehension than their "garden-variety" coun-
114 Michael E. Spagna

terparts. In his fascinating book The Modularity of Mind (1983), Fodor, ex-
plains how the field of "faculty psychology" might explain the behavioral
differences witnessed in my research. Fodor describes "horizontal facul-
ties" as including broad cognitive functions like memory, linguistic com-
prehension, attention, etc.; "vertical faculties," by comparison, are
described as modules of encapsulated information such as phonological
awareness, the ability to decode words. Stanovich (1990) has applied Fo-
dor's conceptual framework of "horizontal faculties" and "vertical mod-
ules" to his own theory: Stanovich has postulated that "garden-variety"
poor readers have a "developmental lag," exhibiting decoding skills and
linguistic comprehension comparable to younger "good" readers; "dyslex-
ic" readers, on the other hand, are believed to have a "phonological-core
deficit/' exhibiting decoding skills similar to younger readers, but also
showing higher levels of linguistic comprehension when compared to
their younger counterparts. According to Stanovich's interpretation of Fo-
dor's theory, dyslexic children have intact "horizontal faculties," thereby
allowing them to accurately interpret the world around them, understand
language and discourse, etc. However, Stanovich also explains that one of
the "vertical modules," the one that encapsulates knowledge of phonics,
is either missing or significantly diminished in the "dyslexic" reader. Stano-
vich explains that "garden-variety" poor readers are not missing the verti-
cal module that encapsulates phonological knowledge but, instead,
cognitive functioning including this "vertical module" are diminished
across the board.

Can Dyslexic Youngsters Become Adult "Garden-Variety"

Poor Readers?

If it is true that dyslexic youngsters experience a specific weakness in their

ability to decode words, then it is also possible that such a localized defi-
cit, over time, might result in broader cognitive deficits. Walberg (1984)
has used the concept of "Matthew effects" to explain how such a phe-
nomenon might occur. This concept is derived from the Gospel according
to Matthew: "For into every one that hath shall be given, and he shall have
abundance; but from him that hath not shall be taken away even that
which he hath" (XXV:29). In other words, Walberg has interpreted this pas-
sage as signifying that "the rich get richer; the poor get poorer" when it
comes to academic gains achieved in the schools. Applying this concept
to the area of dyslexia, Stanovich (1988) explains that, if left unchecked, a
severe reading disorder ala that experienced by "Dysphonetic" dyslexics
might result in decreased cognitive functioning. Extending this concept to
 All Poor Readers Are Not Dyslexic 115

the different types of readers I have been describing tonight, it is not im-
possible, as Stanovich (1990) has pointed out regarding Figure 8, that a
young "dyslexic" reader might become a "garden-variety" poor reader
over time.

INTERVENTIONS AND TEACHING TECHNIQUES

One of the best interventions for children with dyslexia is working with
them on their decoding skills, helping them pick up information to help
them circumnavigate, or get past, some of the problems they have sound-
ing out words. It's not as easy as that, because some dyslexic children are
going to learn best using a sight-word system instead of a phonics system
to teach word identification. By ignoring the fact that dyslexic children ac-
cess words in different manners (refer back to Figure 8), one might believe
that reading problems could be cured just by teaching phonics. About
seven or eight years ago, this was the educational method of choice, not
recognizing that some children will experience difficulty learning to read
using this approach solely.
By not recognizing reading differences and employing alternate
educational strategies to teach reading, a disturbing scenario unfolds: A
child has been identified as having a decoding problem, in spite of the
fact that he/she also exhibits high levels of cognitive functioning, re-
ceives instruction in phonics, regardless of the fact that he/she learns
faster using a sight-word approach. As a result of using a less effective
teaching strategy, this student begins to experience a delay in his/her
reading compared with a comparable school-age peer group. As this stu-
dent gets older, the gap between he/she and his/her peers gets wider.
It should also be pointed out that since students receive a consider-
able amount of information via reading in the classroom, if such a gap
were to develop, widening incrementally over the years it might be high-
ly likely that an individual's understanding of language, and the world in
general would be severely restricted. Essentially, for children with read-
ing problems, knowledge of the world starts dropping off because these
youngsters are not able to access information in the same way "good"
readers do. So, a child's educational prognosis, if he/she has a reading
problem and if he/she doesn't receive early intervention, gets worse
over time.
What, if any, implications do the work of Stanovich and Fodor have for
the front-line teacher? First of all, it is important to point out that the class-
room teacher will be sensitive to individual differences in reading among
116 Michael E. Spagna

his/her students, and it is this awareness of reading differences that

proves to be the single most important factor in teaching "dyslexic"and
"garden-variety" poor readers. A teacher must recognize that reading
skills can be mapped on two axes (see Figure 8): phonic reading, and
whole word reading. All youngsters will have some combination of these
approaches to reading the printed word. Once one recognizes that not
all children have excellent phonic and whole word reading capabilities, it
is quite easy to design curricula to address the learning style of individual
youngsters instead of forcing all poor readers into a phonics approach.
Secondly, the reading equation proposed by Gough and Tunmer indi-
cates that decoding is only one of two important variables, each making
a significant contribution to reading comprehension; the other variable
is linguistic comprehension. Teachers should be giving each of these
three variables equal attention: Children need to be able to decode unfa-
miliar words; they should have sufficient linguistic comprehension to
make sense of the world around them; and, they should be able to apply
both decoding and linguistic comprehension to make sense out of the
material that they read. Without sufficient attention to these factors,
teachers will, in many cases, witness "Matthew effects"; Students will
learn less and less since their main avenue of receiving information, read-
ing, will have effectively been limited.
For the "dyslexic" and the "garden-variety" poor reader alike, teachers
must offer direct instruction in phonics as well as providing an enriched
environment—one that encourages new experiences and is filled with
language via discussion, conversation, and presentations. Let's focus on
the first part—phonics. To be more specific, teachers can approach de-
coding instruction from one of two directions: (1) "meaning emphasis";
(2) "code emphasis" approach. The "meaning emphasis" approach in-
volves exposing children to language in books and words so that slowly
they begin to acquire a whole-word vocabulary. In the "code emphasis"
approach, phonics is taught directly, waiting to teach word meanings lat-
er. By and large, the "code emphasis" approach is taught in one of two
manners. The "Analytic Method" exposes children to words that are simi-
lar except for one phoneme that has been changed (e.g., "pat," "mat,"
"fat"). Another way of teaching phonics, using the "code emphasis" ap-
proach is known as the "Synthetic Method," whereby separate pho-
nemes are taught in isolation and are later blended together to signify a
whole word (e.g., "s," "a," "t" are taught first; then they are blended to
become "sat").
Although the "code emphasis" approach has been the educational
 All Poor Readers Are Not Dyslexic 11 7

technique of choice for assisting poor readers, current research (Bryant

& Bradley, 1985) indicates that children don't learn how to decode
words by breaking them into phonemes (Analytic Method) or by blend-
ing phonemes back together (Synthetic Method). Some children might
benefit from these techniques, but, by and large, children learn different
phonemes by rhyming. Bryant and Bradley (1985) report that, instead of
learning sounds phoneme by phoneme, children are sensitive to two
parts of a word: the "onset," the beginning phoneme, and the "rime," the
rest of the word. For example, in the word "nest," the "onset" would be
the phoneme "n," and the "rime" would be the rest of the word "est." In
short, Bradley and Bryant propose that children eventually come to un-
derstand the importance of phonemes by discriminating between words
that begin with different phonemes but end with the same "rime" (e.g.,
"nest," "best," "test"). Bryant and Bradley continue to explain that it is
this understanding of "onset" and "rime" that allows a child
s phonological awareness to emerge; youngsters become sensitive to
phonemic differentiations and slowly recognize that these phonemes
have distinct identities.
As a result of this discovery, Bryant and Bradley (1985) have devel-
oped a powerful new educational technique that consists of teaching
children how to rhyme words. Bryant and Bradley base this intervention
on their findings that children who experience difficulty rhyming early
on, have a higher probability of encountering decoding and, hence,
reading problems later in life. On the other hand, children who are good
rhymers were found to become good readers later on.
What children's book would be an excellent way of teaching rhyming?
Dr. Seuss, of course! I have recommended Dr. Seuss books to parents of
youngsters, regardless of whether their children are experiencing read-
ing difficulty or not. Dr. Seuss books accomplish two objectives: First,
they teach rhyming in a fun and novel manner; second, they employ
"nonsense" words, allowing children to explore their understanding of
phonics without confusing this understanding with common, high fre-
quency real words. If one can teach youngsters to "play" with language
by using "nonsense" words, children can develop a keen sense of pho-
nics.

SUGGESTIONS FOR PARENTAL INVOLVEMENT

Now, I would like to offer some advice to parents of children who are ex-
periencing reading problems. First, it is extremely important for parents to
11 8 Michael E. Spagna

read to their children, especially at an early age. Get them the information
that they're being cut off from in school. Read to them, expose them to
different experiences vis-a-vis trips to museums, national parks, zoos, etc.
If parents have a young child that they suspect might have dyslexia, they
should expose their youngster to "rhyming games." As I have already
pointed out, one excellent source of rhyming can be found in the Dr.
Seuss books.
Secondly, actively encourage discourse in the home through con-
versations with adults and between siblings. Remember, that parents
must present information in novel ways, since the printed word is so diffi-
cult to decipher. Parents should make sure, whenever the opportunity
presents itself, that their child's world is filled with language—whether it
be dinner conversation, exposure to new vocabulary, etc. When I make
this suggestion, I don't mean showing flash cards but, rather, providing
activities that are language oriented.
By reading to children and actively engaging them in conversation,
parents can keep their children intellectually and educationally afloat as
they go through a potentially frustrating—and consequently, emotion-
al—period of their lives.
These suggestions, so far, pertain to the younger dyslexic child. What
happens to the dyslexic adolescent who has already been in school for
several years, not receiving the interventions I have mentioned? Do par-
ents focus on phonics exclusively? The answer to this question is "no."
As the dyslexic child becomes an adult, increasing emphasis should be
placed into the provision of appropriate accommodations, so the dyslex-
ic adult can access information in spite of his/her poor reading skills. For
someone who is graduating from high school, it is important to provide
tools such as "books-on-tape" that will allow the dyslexic adult access to
important real-world information.
During my tenure at the Disabled Student's Program at the University
of California at Berkeley, many of the dyslexic students that I worked with
complained that they didn't want to read textbook chapters, because
they had to read word-for-word an extremely laborious and frustrating
task. With "books-on-tape," however, these very same students stayed
on top of their assignments, learned the requisite information, and went
on to earn an undergraduate degree. That's not to suggest that dyslexic
adults shouldn't be taught how to increase their decoding and compre-
hension skills; this should be a lifelong endeavor, or at least until the dys-
lexic adult reaches a reading level that he/she is comfortable with.
 All Poor Readers Are Not Dyslexic 119

CONCLUSION
One last point I wish to make is that dyslexia is not a disease like measles.
If one has to think of dyslexia as a medical phenomenon and it most surely
involves neurological functioning one should think of it as analogous to
obesity (Stanovich, 1990). People who are overweight to a certain degree
are considered to fall into the category of "obesity." Obesity is a medical
phenomenon that is researched for potential causes, and interventions are
designed to prevent people from becoming obese. Considering for one
last time Figure 8, the continuum of good and poor readers, one must ac-
knowledge that statements such as, "This child is dys/exic" and, "This child
is not dyslexic," fly in the face of all of the research I have presented. Dys-
lexia, like being overweight, should be thought of as a real, albeit relative
phenomenon. All individuals have different reading strengths and weak-
nesses; some people have excellent whole-word reading skills but poor
decoding skills; others have excellent decoding skills but poor whole-
word reading skills. Because dyslexia has become an "either-or" phenom-
enon, many children are not receiving the instruction they require since
they have not been identified as "dyslexic." And many children originally
identified as having dyslexia are denied services later in life when they no
longer qualify as having a "severe" reading problem.
All of the information that I have presented tonight has given us some
insight into how children learn to read; this information should be an in-
tegral part of their education for the rest of their lives.

QUESTIONS AND ANSWERS

Question: Do you see movement within the continuum depicted in

Figure 8?
Dr. Spagna: This is an important question, and now I'm going to focus
on the New York Times article I referred to earlier in the evening. The
article reports a study out of Yale University that concludes that dyslexia
is not a life-long phenomenon. You can see on the continuum of reading
skills depicted in Figure 8 that, maybe, if certain skills improve say whole
word reading skill, for instance—a child might move out of one quadrant
and towards another. The Yale research group has already addressed the
question by stipulating that, eventually, some children experience skill
development. Unfortunately, instead of stating that poor readers might
experience some gain in phonic or whole word reading skill, the New
York Times article left the public with the impression that dyslexia was
"curable."
120 Michael E. Spagna

Dyslexia is not a medical condition that is "cured." A better way to de-

scribe dyslexia is to emphasize that all individuals experience differences
in their ability to apply phonic and whole word reading skills when at-
tempting to derive meaning from text. It should be expected that chil-
dren who receive direct instruction in phonic reading skill should
experience improvement and, hence, would move to a slightly different
position along the reading skill continuum.
Question: I saw something in Scientific American which pointed
more to the biological aspects of dyslexia. Is there any truth to that?
Dr. Spagna: I would say that the whole area of brain research is still in
its infancy and we definitely still have a way to go in this area. As I ex-
plained in the modularity theory, we don't know why dyslexic children
are missing this one vertical module while all of their horizontal faculties
are intact. The hard thing to decide is whether something happened to
the brain early and therefore the module was lost, or did the child lose
the module and then the brain didn't develop the same way? We still
don't have enough knowledge of neurology and brain function to be
able to figure out this "chicken-and-egg" debate. I think we need to know
if there are any types of biological precursors to the development of pho-
nological awareness. For instance, Galaberta, at Harvard, and other
people, are doing research that I would fully encourage. Without this re-
search, we will never determine the etiologicat reasons for dyslexia.
Question: How can you test for dyslexia if these "Matthew effects"
actually exist and if the child has poor reading skills and later on has a
cognitive deficit as a result of this? Should we test the student later inlife?
Dr. Spagna: If you think about intelligence tests, they are language-
loaded. So, a child who might have language deficits as a result of his/her
reading problem, because he/she has inadequate phonological skills,
will do poorly on an intelligence test. Is that child going to be diagnosed
dyslexic? NO; because they don't meet the cut-off. They might have had
a big gap between aptitude and achievement if they were tested when
they were young, but as they got older, the discrepancy no longer exists.
So, in this instance, I would say that, especially if it's an older learning
disabled individual, you would have to really ask, "What is the intelli-
gence test testing?" And, "Is that the best method for determining apti-
tude?" I'd probably say, "no." You would have to go back into the child's
history to determine whether early precursors were present: Were there
teacher reports that showed that the child had difficulty reading at an
early age? Did the parents notice early signs of reading difficulty? Was
language acquisition later than normal?
 All Poor Readers Are Not Dyslexic 121

Then, you can side-step the state eligibility criterion—that the child has
to exhibit a significant discrepancy between aptitude and achieve-
ment—and consider school history, family history, medical history, etc.
as an indicator of reading problems. You can act around the pure dis-
crepancy definition of dylexia by looking at other sources, primarily fami-
ly and educational background.
Question: You didn't say anything about writing. Are you dissoci-
ationg that from what we're talking about tonight?
Dr. Spagna: No. Quite contrary. I think reading and writing are very
much intertwined, but I just didn't have the time tonight to talk about it. I
think many children learn to read via their experimentation with the writ-
ten word.
Question: How important is the emotional or motivational attitude of
a learner?
Dr. Spagna: There have been quite a few studies, especially in the area
of "Attribution" theory which are relevant to learning and motivation.
Younger children are not as upset when they encounter difficulties in read-
ing. Reading is a new phenomenon, so they're willing to make mistakes.
Later on in life, though, as these children move from elementary school to
junior high school, they start adding emotional reactions to the fact that
they can't read. There's an excellent book by Seligman which is called
Helplessness. He talks about the classroom and mentions that, if students
are not being stimulated by their educational environment, sooner or later
they'll "turn off" to all education. Now, I would have to agree with Selig-
man's assessment. I have met adults with learning problems, who didn't
have their problems addressed, who won't pick up a newspaper or read
because it's so painful for them emotionally.

REFERENCES

Baron, J., &Strawson, C. (1976). Use of orthographic and word-specific knowledge in reading
words aloud. journal of Experimental Psychology: Human Perception and Performance,
2, 386-393.
Berger, Yule, & Rutter (1975). Cited in R. M. Knights & D. J. Bakker (Eds.), The neuropsychology
of learning disorders. Baltimore: University Park Press.
Boder, E. (1973). Developmental dyslexia: A diagnostic approach based on three atypical
reading-spelling patterns. Developmental Medicine and Child Neurology, 15, 663—681
Bryant, P., & Bradley, L. (1985). Children's reading problems. New York: Basil Blackwell.
Coltheart, M., Patterson, K., & Marshall,). C. (1980). Deep dyslexia (2nd ed.), New York: Rout-
ledge & Kegan Paul.
Ellis, A. W. (1985). The cognitive neuropsychology of developmental (and acquired) dyslexia:
A critical survey. Cognitive Neuropsychology, 2, (2), 169-205.
122 Michael E. Spagna

Fernald, G. (1943). Remedial techniques in basic school objectives. New York: McGraw-Hill.
Fodor, J. A. (1983). The modularity of mind. cambridge, MA: MIT press.
Gough, P. 8., & Tunmer, W. E. (1986). Decoding, reading, and reading disability. Remedial and
Special Education, 7, (1), 6-10.
Hinshelwood, J. (1917). Congenital word-blindness. London: H. K. Lewis.
Kirk, S. A. (1962). Educating exceptional children. Boston: Houghton Mifflin.
Orton, S. T. (1928). Specific reading disability—strephosymbolia. Journal of the Amen can Med-
ical Association, 90, 1095-1099.
Public Law 91-230 (1969). Children with Specific Learning Disabilities Act Washington, DC:
U.S. Department of Health, Education, and Welfare.
Public Law 94—142 (1975). Education for All Handicapped Children Act Washington, DC:
U.S. Department of Health, Education, and Welfare.
Rutter, M., & Yule, W. (1975). The concept of specific reading retardation. Journal of child
Psychology& Psychiatry, 16, 181-197.
Sabatino, D. A. (1981). Overview for the practitioner in Iearninf disabilities. In D. A. Sabatino,
T. L. Miller, & C. Schmidt, Learning disabilities: Systemizing teaching and service delivery,
1—24. Rockville, MD: Aspen.
Shaywitz, S. E., Escobar, M. D., Shaywitz, B. A., Fletcher, J. M. & Makuch, R. (1992). Evidence
that dyslexia may represent the lower tail of a normal distribution of reading ability. The
New England Journal of Medicine, 326, (3), 145-150.
Shepard, L.A., Smith, M. L., & Vojir, C. P. (1983). Characteristics of pupils identified as learning
disabled. American Educational Research Journal, 20, (3) 309—331.
Stanovich, K. E. (1990). Explaining the differences between the dyslexic and garden-variety
poor reader: The phonological-core variable-difference model. In J. K. Torgesen, (Ed.),
Cognitive and behavioral characteristics of children with learning disabilities, 7—40. Aus-
tin, TX: Pro-Ed, Inc.
Stanovich, K. E. (1988). The right and wrong places to look for the cognitive locus of reading
disability. Annals of dyslexia, 38, 154—1 77.
Warner, M. M., Schumaker, J.B., Alley, G. R., & Deshler, D. D. (1980). Learning disabled ado-
lescents in the public schools: Are they different from other low achievers? Exceptional
Education Quarterly, 1, 2 7-36.
Wiederholz, J. L. (1974). Historical perspectives on the education of the learning disabled. In L.
Mann & D. Sabatino (Eds.), The second review of special education, 103—152. Philadel-
phia: JSE Press.
Woodcock, R. W., & Mather, N. (1989). Woodcock-Johnson Psycho-Educational Battery-Re-
vised (examiner's manual). Allen, TX: DLM Teaching Resources.
Ysseldyke, J. E., Algozzine, B., Shinn, M. R., & McGuire, M. (1982). Similarities and differences
between low achievers and students classified learning disabled. Journal of Special
Education, 16, (1), 73—85.
LECTURE 6

A. Martin Goodman, Ph.D.

Clinical Psychologist

FAMILY DYNAMICS AND

LEARNING DISABILITIES

"You never pitied me, yet I felt you understood my struggles.

I can have my doubts and at the same time still feel strong."
124 A. Martin Goodman

Introduction by Richard L. Goldman

As we continue our speaker series, we are fortunate to have as our speak-
er tonight an individual who is a clinical psychologist in private practice
and a trained psychoanalyst. For twenty years, Dr. Goodman has special-
ized in individual therapy with children, adolescents and adults as well as
couples and family treatment. He is currently the Consulting Psychologist
for Landmark West School, serves as a clinical supervisor and was pre-
viously Director of the Adolescent Drug Treatment Program sponsored by
the National Institute of Health.
In addition, through the years he has conducted many presentations,
seminars and university lectures.
Dr. Goodman has extensive experience working with individuals who
have learning disabilities and attention deficit disorder. Of particular in-
terest is the subject of the inner world experience of these people and
their families. Tonight's presentation will address this concept as the
foundation for the development of self esteem and self advocacy.
To address "Family Dynamics and Learning Disabilities," Dr. Martin
Goodman.

Dr. Martin Goodman

Family dynamics and learning disabilities is a demanding topic for all of us.
Being a parent under the best of circumstances is a difficult task. Certainly
when there is a young person in your family with a learning disability, par-
enting is even more difficult. Many times we feel helpless and frustrated
and, in these circumstances, often the best of who we are does not come
through. The purpose of this evening's presentation is to explore and un-
derstand not only the experience of the LD child, but that of his family as
well.
Those of you who are here for professional interests, and who do not
have LD children, will also find this information useful. Insight into the
parenting process is valuable for all of us. We all need to work at parent-
ing. We put so much energy into other aspects of our lives (at the work-
place, for example), but we often fail to realize that parenting is a process
requiring particular skills needing to be cultivated. We have often heard
the saying, "It is easy to become a parent, but being one is very difficult."
In the course of this evening's discussion, as we explore thestruggle with
the parenting process, I will add the following: "All parents make mis-
takes—mistakes are an integral part of the learning process. Probably he
who never makes a mistake never makes a discovery."
 Family Dynamics and Learning Disabilities 125

Our goal is to learn how to be an advocate for the LD child and to help
him or her become an advocate for themselves. All of these children
have numerous strengths and abilities which we draw upon to aid in this
process. However, tonight I will be focusing on some of the internal
struggles these children have. You may at times say to yourselves, "That's
not my child" or, "My child is not that bad off." But to some degree your
child will share some of the characteristics I will be describing this eve-
ning.
When we think about your child as an advocate for him or herself, the
most difficult part is overcoming their feelings of being alone with their
struggles. We want to turn the feelings of defeat into experiences in
which young people can gain an internal voice that says, "Hang in there,
it's O.K., I'm with you." If they do not have an internal voice that comes
through family experiences, then they will feel isolated. I want to convey
to you the LD child's internal emotional tone. In our search for this inner
feeling, it is essential that we understand our young people and their vul-
nerabilities.
I want to convey how we may hear their struggle, so they will not feel
alone in this life. It is bad enough that a youngster has a learning disabil-
ity, and many times the learning disability will persist. It is crucial that we
help them develop a depth of self-understanding out of which self-es-
teem will emerge so they can effectively cope with their difficulties.
Learning disabled children embody a broad range of characteristics.
Some have almost imperceptible learning disabilities and are intact in
many ways. Others have a pervasive learning disability. We find that
many ID children have varying levels of performance., so that while they
may have exceptional capacity in some areas, they may be significantly
deficient in others. What we want to do is build self-esteem that enables
them to say, "Well, O.K., / will have obstacles and embarrassments be-
cause of my learning disabilities, and some of these I cannot overcome.
But if there is one thing that my school and my family has taught me, it is
how to hang in there and still believe in myself." We want to help them
gain the internal as well as external skills to persevere in the face of adver-
sity. After all, if all of us could do this in life, we wouldn't be doing so
badly either.
Learning disabilities are seen in both active and passive forms. Some-
times we see attentional deficits which are active and the youngster is
acting out all over the place. We also see the passive child. This second
type of child is withdrawn, very shy, and presents a very vulnerable pic-
ture. The second youngster does not want to take on anything new for
126 A. Martin Goodman

fear that he will experience another defeat. His or her daily life is often in
the form of crisis.
In my clinical psychotherapy practice, I frequently ask, "What's new
this week?" However, in most people's lives, things do not change much
from week to week. But with LD kids this does not hold true, for there is
always something new. Every single day is filled with difficulties. They
cannot sit still, they daydream, and they are often seen as troublemakers
because they lack the capacity to constructively verbalize their anger
and frustrations. As a result of this, they are often in a state of crisis.
We want to assist these young people with the communication and
articulation of their feelings. It is very difficult for them to transform inter-
nal experiences, feelings and thoughts into language. What we will try to
do this evening is to focus on how to help them so that they can bring
what is inside to the outside. This is a very therapeutic thing to do.
Learning disabled children cannot easily read social cues and do not
know how to fit well into social groups. Psychological maturation is
learning about the shades of grey in social situations. For example, an
adolescent who is not yet mature psychologically, like an adult, has the
tendency to see the world as black and white. Little children will say sim-
plistically, "Is he good or is he bad?" However, as we progress through
life, gaining wisdom, most of us are able to determine shades of grey and
subtleties within our social context. However, the learning disabled child
does not grasp that part of social processing and does not know about
shades of grey. They do not know to enter a social situation in which they
must read the many subtle cues and then work their way into the setting.
Thus, many times we are working with a lonely child, one who stops try-
ing socially because he anticipates defeat. Everyday activities for LD chil-
dren can thus become crisis experiences. If most of us are on the
periphery of a group occasionally, this is O.K. But if this is your daily ex-
perience, if others say things that you don't understand and continually
humiliate you, daily activities become continual crises.
This is especially true for some types of LD adolescents. If you could
go back to any age of life, how many of you would like to go back to the
seventh grade? I do not think many of you would choose to do so. It is a
time during which there is much turmoil.
We will talk later about the LD adolescent, because this is an area of
special needs and it is a particular interest of mine. However, for the mo-
ment, let us continue with the daily mini-crisis of the LD child.
For example, the child with both an attention deficit and a learning dis-
order who leaves home without his lunch experiences mini-crisis. Even
 Family Dynamics and Learning Disabilities 127

though you remind him a dozen times, he still forgets. Even though he
forgets, it does not mean that he does not care and, as a result, he often
feels ashamed. Another example of a situation like this would be when
confronting a difficult exam. The child may not only feel that he did not
succeed, but also may feel deep shame because of repeated failure. It is
one thing to do poorly in an examination, but imagine this failure after
you really studied. Other people will often think you are lazy, even
though you know you tried very hard. Think of your own experiences.
Since some of you may be learning disabled also, you can become an
ally to your son or daughter. The fact that you were learning disabled
may prove to be an asset. If this is true, then you might become better
able to get in touch with your son or daughter. Search yourself and try to
remember what it was like to be that age. Now, picture yourself as being
an LD child studying for two hours before an exam and then, just when
you think you might have conquered the exam, you get it back with a
grade of 'D'!
The child might say, "They always tell me I'm not stupid," but deep
down, the child feels stupid. The last thing we want to have happen is for
that child to carry a sense of defeat and shame in an isolated fashion. If
the feeling remains isolated, and cannot be understood by others who
are able to reach out and to feel that disappointment also, the child will
simply wall off the feelings, and the feelings will become part of an accu-
mulation of shaming experiences. This will eventually turn into what is
referred to as "chronic shame." This is the kind of shame that occurs
when someone comes in contact with certain experiences and shame
becomes overwhelming. The LD child thus starts developing a phobic
avoidance toward academics.
A little bit of shame is common for all of us. We all cannot do every-
thing well; all of us will be better at one thing or another. However,
chronic shame to the self is the type of shame that builds up and says, "1
am a poor excuse for a person." The shame is not centered around an act;
it is centered around the identity of the person. This kind of shame is part
of the everyday life of the LD child.
If you see that type of shame displayed in your child, do not deny or
dismiss it. Rather, be understanding and sensitive. Even though LD chil-
dren may look very happy and may be doing O.K. in other ways, they feel
shame because of all the secrets they hold inside. We try, of course, to
help remediate their difficulties and sometimes we can be very success-
ful, particularly in schools like Landmark. One of the remarkable oppor-
tunities the child has here is not only to have things targeted for
128 A. Martin Goodman

remediation, but also to obtain sensitivity from the staff. If something

seems overwhelming, the staff has a way of breaking the problem down
into manageable parts so the child does not feel desperately inadequate.
It is a way of reaching out to them and it serves both an educational and
an emotional function.
I am focusing on a whole range of emotions common to LD children,
including the feelings of shame, inadequacy, low self-esteem, hopeless-
ness and helplessness, all of which LD children experience. They are vul-
nerable to insults from peers and from siblings. In the family, siblings can
be quite mean. When they get really angry, they can hit below the belt.
The LD child becomes shamed and stores unresolved problems internal-
ly. Their reaction may be tremendous rage, which is a byproduct of
shame reactions, or they may just give up, defeated, saying to them-
selves, "The hell if I will expose myself to further defeat or embarrass-
men t."
In the past, your child may have had teachers who did not understand
their learning disabilities. These teachers might have said, "Come on, you
can do it," and maybe even meant well but, in essence, they shamed
them because they did not really understand. It was not that the child
was not trying, but that they really needed special help to solve the prob-
lems.
Parents may also be involved in producing these self-esteem difficul-
ties. It is not uncommon to have one parent more convinced about the
presence of a learning disability, while the other parent thinks that, "The
child is just lazy." It is a very difficult situation in which the LD youngster
may find himself. We all want our children to succeed in this world. We
are afraid for our children and, as parents of LD children, you must de-
cide to what degree do you push them, and to what degree do you ac-
cept their deficit? This type of question is better answered when we
understand both the educational as well as the emotional realities. There
are ways to encourage young people when we have genuine insightinto
their special learning problems, as well as to the feelings surrounding
their difficulties.

ACTIVITIES OUT OF THE HOME

Finding appropriate activities out of the home is difficult. LD youngsters
may have few friends. They also have many problems with poor judge-
ment. Once again, they have difficulty with the various social cues, the
contextual meanings that involve shades of grey, and the ability to think
 Family Dynamics and Learning Disabilities 129

things through like their non-LD sibling. And so, parents may often get furi-
ous with them. Parents will state with anger and exasperation, "I thought
you knew better. How could you have done that!" Many negative acts by
the LD child are simply ways of communicating their frustration.
Many of these children who have difficulties in articulating their feel-
ings and thoughts often get in trouble because they do not have any real
way of saying what they need to say. They have difficulties knowing why
they were angry or why things were unfair or unjust. Instead of articulat-
ing, they retaliate and do things which are equally unjust. They will seem
to be saying by their actions, "You see what it feels like? I'll show you—try
this one on for size!" Consequently, they get into more trouble. When
they are sent to the office for behaviors like this, they sit there with self-
righteous indignation. What they are really feeling inside is, "Did you see
what happened to me, how unfair things are?"
In addition, learning disabilities directly relate to study habits. When
they look at their books, they think about how inadequate they are. One
of our tasks as parents and educators is to help young people deal with
these feelings of inadequacy and learn how to resolve and tolerate these
feelings so that they will not sit at their desks with their books shut. One
of my tasks as a consultant at Landmark is to work with the staff and help
them form links and connections to the young people. In the tutorial, or
prep program, we try to help the staff prepare students for life itself.
Every child wants to feel special. But how do LD children feel good
about themselves when others, as well as their siblings, perform more
adequately than they do in many ways? One of the common things we
say about LD children is, "Let's help them by building upon their
strengths." But with some LD children, it is sometimes difficult to find
their strengths compared to those of their siblings. We really have to look
for strengths, and this requires special skills and sensitivities.

SIBLING PROBLEMS

Let's talk about the interactions between LD children and their siblings.
The child often has a lot of resentment directed toward their siblings. Sib-
lings are perceived by them as perfect. It is a natural experience for an LD
child who is experiencing defeats in life. The youngster might feel deeply
conflicted about feeling resentment towards competent siblings, because
they really like their brother or sister. The able sibling may be working very
hard to succeed, but have difficulty understanding that. Because there are
so many problems, he often gets the lion's share of parental attention.
130 A. Martin Goodman

Thus, there are many mixed feelings that the siblings have towards their LD
brother or sister who may be getting more parental time and attention.
Many times, besides the simple resentment that they feel, there is a whole
host of other feelings that are present. Normal siblings often feel guilt to-
ward their LD sibling. Because they are doing so much better, they can
sense and see the pain on the face of their LD brother or sister. The
academically adequate child may just waltz in with A's, or be successful in
sports, and they feel a little guilty about this because they do not want
their brother or sister to feel badly in comparison. However, their guilt is
not as strong as their normal desire for positive attention and a need to be
special. No child can resist this. Moreover, they are entitled to have the
family resonate with their success. They are often angry that they have a
brother or sister whom they feel guilty about. Many times, when this an-
ger goes unexpressed, it becomes bottled up and comes out as resent-
ment.
Academically average siblings may also feel guilty because they are
often embarrassed by their ID siblings. If they have a brother or sister
who, by their standards, is not in the mainstream, they are embarrassed.
So these normal siblings may experience turmoil. They also may love
someone they do not like. Additionally, they feel pressure to succeed be-
cause of the presence of an an LD sibling, and they do not want to let the
parents down by being another problem child. Many of them are hurting
or struggling or have their own problems, but they see their parents
struggling with their troubled sibling and, thus, they may keep all their
problems to themselves. In addition, they may also see an older LD sib-
ling having serious problems in the upper grades and think that, "The
higher grades must be terrible. Is that what it is like; do you fall apart
when you get older?"
There are all sorts of natural feelings of rivalry in every family and the
whole phenomena complicates this rivalry. Sometimes rivalry and result-
ing competition can be healthy in circumstances where there is enough
love to go around. The children will push each other and that results in
healthy striving. When a LD child is involved, however, the child is vulner-
able to feelings of inadequacy and defeat.
Lastly, the competent sibling of an LD child often has to live with the
burden of being the object of tremendous envy. They live with the inner
sense that another person somehow wants them to fail. (Actually, we all
have those feelings, in the internal corners of our inner life.) Thus, when
that sibling has a defeat, there is a part of that LD child who is rejoicing.
The healthy brother and sister know it. They live with this feeling and it
 Family Dynamics and Learning Disabilities

creates pain for them. As parents, it is crucial that we not judge these
normal reactions in our children, but respond with a level of sensitivity
and assist with understanding so that they may integrate these feelings.

SOLUTIONS

Let's continue to talk about some solutions. I will first go over some ideas
as to how to communicate with these children. I will try to deal with the
parents' experiences. After this, I will answer some questions and try to
develop a dialogue. In a dialogue setting, I can get my clinical orientation
out, as most of the time I work in a clinical setting. The only real control we
have as parents is over ourselves. You cannot really control your children.
You can try to control your child, but it does not work. What I would like
you to do is to learn how to control yourself and to be in touch with your
emotions and feelings. As parents, your job is to teach your children to
become more effective people in this life. Thus, the most crucial thing you
have to do is to provide successful models through good communication.
This means effective communications about abstract ideas, as well as
about everyday life.
One of the big obstacles parents have is to come to grips with the fact
that they have significant feelings of loss and disappointment with regard
to their LD child. When the child is in the cradle, all parents first think,
"Well, he can be what he wants to be." When parents see that their child
is learning disabled, parents may feel that their dreams for their child
have been shattered. You need to be honest with yourselves. Freud said
that, "Children read our unconscious, not our conscious." In other words,
they see our moods, they read our body language, they watch us and
study us and see our emotions from their birth. They know at some point
how you feel about them and what you think. I suggest to you that unless
you search yourselves for your own true feelings, they will come across
anyway. So you must get control of yourselves so that you can get a
sense of what is coming across to your children.
With any sense of loss, there usually occurs a three step process.
These steps involve denial, anger and acceptance. Often, when parents
first hear that their child is learning disabled, they first think that the
school is wrong, or they just do not know "my child," or they do not
know how to work with "my child," etc. This is upsetting and this consti-
tutes a state of denial.
Then anger comes, as this is part of denial. Parents think, "Let's find a
new school!" The parents still have not accepted what their child needs.
132 A. Martin Goodman

There are a number of parents who have their children here at Landmark
that need to look at their own denial process. They have accepted the
basics of the children's learning disabilities. However, they still need to
acknowledge their own unresolved feelings about this fact. One of Land-
mark's goals is to give children the sense that they are in as normal a
school setting as possible. The staff here wants to give children the feel-
ing that they are part of a large social system, and to accept real life. Yet,
on the other hand, these children cannot do all things.
There was a final examination period recently, in which some of the
children were "freaking out" over their examinations. For some, it was
too much; they could not cope. There were other children who did quite
well. They needed, however, to learn to cope with this type of situation,
as life presents many situations which involve final exams. Life is full of
pressure situations, so it is appropriate for Landmark to carefully ap-
proach the examination period as an opportunity to learn how to more
effectively cope with pressure.
We have parents here at Landmark who sometimes state that, "My son
or daughter has to get a good grade in this algebra examination because,
if he doesn't, he will not get into college." While it is true that parents
must face the fact that some LD children will not go to college, there are
many learning disabled children who will go to college. My brother-in-
law is learning disabled and he majored in his strength, music. However,
it took him six years to graduate and it was tough for him. For those who
will not make it into college, we have to begin to deal with this possibility
and with our own disappointments as parents. We should not project
our negative feelings onto our children, and thus make our youngsters
feel ashamed of themselves.
For example, if you wanted your child to become an attorney, it is bet-
ter not to ignore your feelings and just pass them off. It is better to come
to grips with your feelings and tell yourself that you are genuinely disap-
pointed with the fact that he will not become an attorney. If you can face
these feelings in yourself, you are not as likely to project them outwardly
towards your child. Whenever you have a lack of understanding, then
you might take the blame. When you have not come to terms with the
pain, you will suffer blame. Parents devise a variety of ways of blaming
themselves. By blaming themselves, they feel guilty. The parent may
think, "1 should have spent more time with him of her," or, "It must have
come from my side of the family." Thus, it is not uncommon for this to
create a lot of family discord. If you have, to cite another example, a hy-
peractive child, you experience difficulties from the earliest stages of his
 Family Dynamics and Learning Disabilities 133

or her life. They may be up every half hour during the first six months of
their lives, and this can drive parents nuts. Parents may then begin to dis-
agree energetically on the parenting style to use, to be too tough or too
lenient. There is usually pain and something needs to be done about it.
When you do not understand it, you will get into a cycle of blame. Some-
times parents will compensate by making their child's problem their rea-
son to live. Everything centers around the child with the problem. But
that is not really what we want to do with these children. We want to give
them balanced social experiences.
So, now we have all these problems. What are we going to do about
them? The answer is simple. Parents should try to become a conduit for
their children, and help them express their inner feelings outwardly. They
can express what is inside with our assistance as parents. We should not
try to shut them down. We should teach them how to deal with a whole
host of emotions. We want to help them through what is called "reflec-
tive listening." Reflective listening works like this: You think of yourself as
mirrors, so that whatever your child says to you, you then repeat it back
to them as a mirror would. Two books are very good in finding out more
about reflective listening. They are: Parent Effectiveness Training by
Thomas Gordon and Step Systematic Training for Effective Parenting by
Don Din kmeyer and Gary B. McKay.
Reflective listening thus involves stating the child's feelings and mean-
ings so that he or she feels that you really hear and understand them.
Every child, particularly teenagers, desperately needs to be understood.
In doing this, we will help them achieve better self-control. We want to
say to ourselves, "What is my child feeling, and what brought on this feel-
ing?" For example, if your child comes home from school and has had a
fight with the teacher, typically the parent wants to get into the problem
immediately by asking, "What did you do, what did the teacher do?",
thus entering the process of assigning blame. What you really need to
do, however, is to help your young person sort the problem out. You
don't want to appear to take sides. You just want to help them reflect
back upon their unpleasant experience.
For example, if your child says, "That teacher was so mean to me, or, I
hate that teacher," the parent should then, rather than assigning blame,
say, "Boy, you really sound angry," which invites the child to tell you a
little bit more. The child might then say, "Yeah, that teacher was really
unfair to me!" Sometimes, at this point, the parent may be tempted to say
something that will shut the child down, such as, "Sometimes you really
do misbehave." Instead, you might say, "You feel the teacher was really
134 A. Martin Goodman

unfair. Tell me about it." Thus, you are not taking sides and you are not
deciding that either the child or teacher was wrong. You are thus inviting
the child to articulate more. The child may then say, "Well, that teacher
singled me out and sent me to the office." It would be tempting at this
point for the parent to say, "You have been sent to the office so many
times, you must be doing something wrong." But, keeping the mirror con-
cept in mind, you can say, "You were sent to the office, that sounds really
upsetting. What happened?" Now this child still has not been shut off,
and is not arguing, and will likely tell you what happened. He might then
say, "Yeah, everyone else in the class was talking and everyone should
have been sent to the office, but she just sent me to the office." The rea-
son I am using this example is that, within my practice recently, I had a
child who was constantly testing the limits. For example, when he was
asked by his teacher to be quiet, he would immediately whisper to a
neighbor and the teacher would say, "Go to the office." It would be very
easy to blame him and to make him defensive. Keeping the mirror con-
cept in mind, I said to him, "You felt you were being singled out. It must
have been terrible." He responded with, "Yes, it was terrible; I hated it.
That teacher had it in for me." This type of communication can give you
an inroad into the child. You may continue with, "You know, sometimes
you are really angry with your teacher, aren't you? But you havealso told
me that he is not so bad. What do you think happened in this situation?" If
you keep him in this reflective mode, you then begin to have a link to the
child. The child may respond by saying, "1 have been singled out." You
might then respond with, "Yeah, I hate to be singled out, and sometimes I
was, and it was terrible." Once again, you have continued to build up a
link; you have held up a mirror. At this time, it could be time to work on a
solution such as, "So, now what do you think we might do to solve this
problem?" If the child says, "It is hopeless; it won't work," you might re-
spond by saying, "1 see you feel really frustrated and you are giving up and
you do not want to really try to solve the problem." Once again, he will
feel that you are linking with his feelings. You can continue in this mode
with, "Let's think of some good ideas together." At this point, neither the
teacher nor the child is being blamed. Thus, you have built up a link of
empathy so that he does not feel that you are putting him down or blam-
ing him. You have not taken a position. You are still in a problem-solving
mode. Part of the problem solving mode could involve helping the child
identify social cues that communicate when the teacher is really serious.
At those times it is essential that no more talking occurs.
 Family Dynamics and Learning Disabilities 135

Let's take another example of a situation cited in the book Between

Parent and Teenager by Dr. Haim G. Ginott. An LD child returns home
from a job interview. During the interview things did not go very well.
The unattuned parent might say, "What did you expect, that you would
get your first job on your first interview? Life is not like that. You might
need to go to five or ten interviews before you are hired." However, if the
parent works as a mirror, they could say, "Gee, I know you were looking
forward to this job and I know you are really disappointed." Thus, you
and your child are on the same team. In contrast, the well-meaning but
unattuned parent would say, "Rome was not built in a day, chin up and go
get 'em, Tiger!"
Although this kind of encouragement can be appropriate, if you sense
defeat in the child, you might say, "You look pretty down about this. I get
the feeling that you do not want to look for other jobs." The child might
say, "Yes, that was a terrible experience." The parent can continue mirror-
ing by saying something like, "You are really humiliated and you feel like
you will never get another job," and the child might respond with, "Yeah,
I feel like I will never get another job." At this point, the parent could say,
"1 know you really want to get a job, let's think together how you can ap-
proach this problem again." The parent can forge a link to their internal
experience. It does not help to minimize difficult situations by saying, for
example, "1 do not see why you are depressed. It was only one job!" If
you do this, they will not only feel discouraged, but they will feel inade-
quate because they are discouraged.
Admonishing children for not having enough self-esteem will not im-
prove self-confidence. The forming of links is an old therapeutic tech-
nique that we use to enhance communication with the child in
non-judgmental ways. It can be quite productive. We also do not want to
pity the child by saying, "Oh, you poor thing. What terrible luck." He is
not a defeated, poor thing, and expressing feelings of pity and denial is
not the way to be in tune with the child's feelings. For example, the child
might say, "1 am learning disabled, I cannot do these things, I cannot fill
out an application." Now you are getting down to a concrete problem.
Again, the parent mirrors by saying, "Boy, that sounds like it was really
awkward and embarrassing." This is not pity. You are not judging their
feelings but, rather, describing their feelings. Now that you have begun
to forge a link, you can continue with, "In the future, you might be able to
bring the application home so that we can fill it out together." We want to
have a working relationship with these kids.
136 A. Martin Goodman

You do not want to take a Pollyanna approach, in which one would

comment, "Everything happens for the best. You did not get that job, but
you will get the next one." We really should not look to rescue children
from painful moments. This is not our task as parents. Our task is to help
them to integrate the pain, and to help them learn from painful experi-
ences. And the best way they can learn is if they feel you are their ally.
They will sense this when they feel that you are attuned to them. To give
another example, your daughter might come home and sadly say, "Bill
and I have just broken up." A response that will not result in a linkage
might be, "You will find another boyfriend, don't worry." A response that
might encourage more involvement would be something simple such as,
"You sound very sad." This encourages the girl to tell you how she feels,
that she really feels down and out, and that she feels that she will not find
another boyfriend. At this point in the conversation more constructive
problem solving may be possible. Adolescence is a time when daily
changes take place. We need to stay close to them and to mirror back
their feelings as we see them.
Now, let us consider anger. If 50 or 100 million American parents are
getting angry at their kids, then we know it is a normal emotion. It is a
part of life. We thus want to teach LD children how to express anger ef-
fectively. Many times, they get into trouble because they do not have the
tools to do this well. So what we need to do as parents is model anger in
effective ways. What we don't want to create is resentment by demand-
ing that they listen to us. They will listen to you and reflect compliance,
but then you will get passive aggression on their part, in which they drag
their heels and are late for things because they are mad at you.
What we really want to do is teach children how to respond. There are
a few basic rules to keep in mind. We want them to describe what they
see, to describe what they feel, and to describe what needs to be done.
In teaching them this, under no circumstances should you ever attack the
child. For example, when the child takes a shower and leaves wet towels
on the floor, one might be inclined to go in and say, "You are so damn
lazy that you could not even pick up a towel!"
It is far more effective to respond by saying, "When I see towels on
the floor, I feel frustrated and upset and I would really appreciate if it you
would pick them up." This is an elemental process. You describe what
you see, then say how it makes you feel and, lastly, state what you want
done about it. To give another example, when a teenager comes home
late, you may be inclined to yell, "You are so irresponsible, you aren't
going out again!" However, a comment such as, "When you come
 Family Dynamics and Learning Disabilities 137

home late, I really feel worried," is much more helpful. It is always good
to encourage a discussion and in this situation you might continue with,
"What do you think we can do about it?" You do not want to directly
attack the youngster. You should simply state that, "I am really con-
cerned when you come home late because I am worried that something
happened to you, and that maybe your car ran out of gas." Another ex-
ample is that many kids do not want to do their homework. In this situa-
tion, you can get into a major power struggle about their homework. If
we engender anger and resentment in a situation like this, our children
will always want to get revenge. Helpful criticism involves saying what
needs to be done in a situation. You address the situation or behavior,
you do not attack the person. For example, if the kid is not studying, an
unhelpful comment would be, "You will never amount to anything in
life." A helpful descriptive comment such as, "You seem to have a hard
time settling down to do this homework," is far more encouraging. You
have not criticized, you have merely described. Wait to see how the
child responds. He might say, "Yeah, I hate it." Again, think of yourself
as a mirror and say, "Yeah, I see you really dislike it. It looks really frustrat.
ing. What do you think we can do about it?" If the youngster begins to
make a battle out of it, use words such as, "You are really angry about
the homework, but I do not want to have a struggle and I do not want to
be on your back. Let's see how we can solve it."

QUESTIONS AND ANSWERS

Question: If my child has a socially defeating experience which I have

also observed, and he does not bring it up, should I be the one to bring it
up for discussion?
Dr. Goodman: We must be careful not to be intrusive to children. And
we want them to feel that they have some control over their own feel-
ings. However, we may use a type of non-intrusive mirroring as a way of
finding out what happened. You might say, "I noted a while ago that you
got in an argument and that some of the kids were really mean to you."
Something that is descriptive and simple is a good way to start. Children
do not want to feel that you are intruding; they need an invitation. They
won't deny that some thing happened and they may say, "I hate those
kids." You might be tempted to respond with, "Yes, everyone gets into
fights sometimes, and that is the way life is." This, however, may shut
down communication with the child, for it says you do not feel their pain.
However, if you take a different approach such as, "Boy, you are really
138 A. Martin Goodman

angry," this is simply reflecting back his feelings. Now you might get to
hear more. Many times kids are worried that you will want to talk about
things that they are not ready to think about, or that you are going to give
them a lecture. But if you keep a low-key approach it may prove encour-
aging.
Question: What do you do when your child takes anger and frustra-
tion out of their siblings?
Dr. Goodman: ID children are often abusers, but we want to teach
them how to defend themselves without becoming oppressors. Nor do
we want them to become oppressed. We do not want them to be cruel
to other people, but we do not want them to be vulnerable to the cruelty
of others. Many times a frustrated child, however, turns into a mean
child. When we see this anger, we may want to use this mirroring ap-
proach and to articulate what their inner experience is. We might want to
say, "Joe, you look so angry." We do not want to say, "Joe, when you get
angry you do stupid things." Rather, we want to say, "Joe, for you to do
that, you must have been really, really angry." You are trying to get in
tune with his feelings. After acknowledging that their behavior is unac-
ceptable and that they are capable of better, we can begin problem solv-
ing.
Question: What about struggles around bedtime? Even after a shower
he is not ready to go to bed until 9:30 or 10:00 p.m.
Dr. Goodman: Your question contained different kinds of feelings.
You should use those feelings when you talk to your child and articulate
your feelings. You should say, "I do not want to treat you like a little kid
because you are really responsible in some areas, but when it is time to
go to bed I notice it is really hard for you to get to bed on time." What is
good about this approach is that it is a description, not an accusation.
This is less likely to provoke defense, and just reflects your feelings. You
are saying that you do not want to be restrictive, but you notice he can-
not take care of this bed problem. After you have this non-blaming link,
you encourage the child to help you think of solutions and what to do
about the problem. You are in a non-blaming mode, and with a teenager
you can start to solve the problem. If the child continues to express anger
such as, "Get off my back," use the mirror once again and he will begin
to feel understood. Then you can start problem-solving. Sometimes they
may come up with ideas that are even more strict than those you might
have come with on your own!
If the child continues to reject the idea of problem-solving, you may
have to offer more mature thoughts. For example, better ideas on how to
 Family Dynamics and Learning Disabilities 139

get to bed on time. If you notice your own anger building up when the
child does not respond, you should continue to describe your own feel-
ings about anger and frustration regarding the present conflict. Don't let
your anger grow very much, and tell the child that you are beginning to
get angry and that you are tired; that you do not want to yell and you ask
the child for help in taking care of this problem. If this appeal to reason
does not work out, you have to discuss alternative plans with your child,
like starting to prepare for bed earlier in this case. Thus, if you institute
punishment, it is not to inflict pain on the child, but it comes as a logical
consequence to not solving the problem of going to bed. You should tell
the child if he does not want you on his back that he should help you in
solving the bedtime problem.
LECTURE 7

Bryanti. Cratty, Ed.D.

University of California, Los Angeles
Professor Emeritus of Kinesiology

COORDI NATION
PROBLEMS AMONG
LEARNING DISABLED
CHILDREN: MEANINGS
AND IMPLICATIONS

"Some say that dyslexia doesn't exist, or that if it does,

it goes away. But dyslexia spans a range from mild to severe
learning disorders, with no single remedy for everyone."
142 Bryant J. Cratty

Introduction by Richard L. Goldman

Tonight's presentation will focus on coordination problems of learning dis-
abled children.
Dr. Bryant Cratty is acclaimed for his work with physical education for
the disabled child. He is a Professor Emeritus from University of Califor-
nia Los Angeles (UCLA) in Kinesiology. Dr. Cratty has written over seven-
ty books and monographs dealing with motor learning, adapted physical
education for the handicapped and developmental psychology.
We are extremely fortunate to have this professional conduct a pre-
sentation in our Speaker Series. Ladies and gentlemen, Dr. Bryant Cratty

Dr. Bryant Cratty

Awkward children, whether otherwise learning disabled or not, are likely
to elicit various reactions from those observing their struggles as they at-
tempt to perform physical tasks. For example, they may be the victims of
social derision from their brothers and sisters. Peers in school may also
ridicule them, and ostracize incompetent performers from games and
sports. Their teachers may become impatient as printed or written lessons
are not copied neatly and rapidly enough to match the efforts of their
physically more capable classmates.
Parents, when confronting evidence of incoordination in their off-
springs, also have reactions that vary from household to household.
Some accurately assess the nature of the problem and seek valid and
thorough evaluations and then obtain professional help.1
Others may ignore the difficulties their children have when attempting
physical skills. While still others may deny there is a problem present,
often citing evidence of their child's intellectual social and/or creative
prowess as ways to counter criticisms of their offspring's poor motor abi-
lities. Fathers may become tense while attempting to play ball with their
poorly coordinated sons in the backyard, and later may withdraw from
such potentially useful encounters. A mother, after receiving reports
from a nursery school teacher that include the words "delayed develop-
ment," may frantically begin to seek a solution to the problem by consult-
ing the family pediatrician, and a number of other medical, educational
and paramedical specialists.
 Coordination Problems Among Learning Disabled Children 143

IDENTIFICATION AND DEFINITIONS

Identification

Physically awkward children may pose evaluation and labeling problems

to professionals assessing them, similar to the problems encountered
when attempting to identify youngsters with learning disabilities. Some
pediatricians, who may have only been exposed to children with obvious
symptoms of cerebral palsy, may shrug off symptoms of incoordination as
simply a collection of unusual neurological 'soft signs'. Furthermore some
may tell parents that the child may outgrow poor coordination, and thus
the problem is not of importance. Many medical specialists, however, are
becoming aware of the existence of the significant percentage of these
children found within apparently normal populations. These doctors ac-
tively assist parents to seek remedial help for their youngster's problems.
Child psychologists, whose evaluation tools usually include collecting
samples of printing and figure drawing, may correctly identify a graphic
problem. However psychologists usually do not assess deficiencies re-
flecting the child's integration of the larger muscle groups. Some learn-
ing disability specialists, and educational therapists may mistakenly
assume that because the child prints slowly and poorly, other academic
difficulties must inevitably be present.

Definitions
Awkward child have been given various labels throughout the past several
decades. They have sometimes been dubbed 'minimally brain damaged'.
This type of definition infers that poor motor coordination is caused by
easily identifiable neurological underpinnings.
Some have referred to physically awkward children as hyperactive, or
possessing an "attentional deficit." Those formulating this type of label
apparently ignore the premise that it is possible for a child to be hyperac-
tive and well-coordinated, or to be uncoordinated and yet evidence
good attention and impulse control.
Others have described awkward children as evidencing developmen-
tal apraxia. The prefix "developmental" usually means that the condition
is apparent early in life, and that the awkwardness observed is reflected
by the inability to integrate task's sub-movements into complex wholes.
Furthermore "developmental apraxia" implies that youngsters given this
label are not mastering appropriate physical skills at the ages expected
by members of their sub-culture.
144 Bryant J. Cratty

An early definition of incoordination was formulated by Gubbay

(1975), who wrote that "the clumsy child is to be regarded as one who is
mentally normal, without bodily deformity, and whose physical strength,
sensation and coordination are virtually normal by the standards of rou-
tine conventional neurological assessment, but whose ability to perform
skilled purposive movement is impaired." Gubbay's description poses
several problems, however. For example, his definition suggested that
the nervous systems does not somehow mediate awkward motor behav-
ior, as he pointed out that conventional neurological assessment will like-
ly reflect normality when applied to such children. However, twenty
years ago Touwne and Prechtl (1970) two Dutch neurologists, and more
recently others (Tupper 1987), have incorporated measures of motor
awkwardness and neuromotor immaturity into well-designed evalua-
tions for children with 'minor nervous dys functions.' Several contempo-
rary neurological-evaluation schedules have been designed to be used
following conventional neurological assessments. Thus it appears that
using contemporary assessment tools and sophisticated strategies, signs
of motor awkwardness are medically identifiable and diagnosable with
reference to the presence of associated neurological dysfunctions.
Recently, clumsiness in children has been defined by Hall (1988) as "a
deficit in the acquisition of skills requiring fluent coordinated movement,
not explicable by general retardation or demonstrable neurological dis-
ease." This definition seems based upon contemporary evidence making
it increasing clear that a child may evidence motor awkwardness inde-
pendent of, and without the presence of, other medical conditions and
learning problems. Furthermore research data appearing in the 1 990's is
beginning to identify the existence of various sub-syndromes within
what was once viewed as a rather global and undifferentiated type of
movement problem. (Hoare & Larkin 1991) (Miyahara 1992).
Awkward children and youth, however, continue to reside in a diag-
nostically 'grey area', similar to the manner in which some learning dis-
abled youngsters are still viewed. They make their peers tense and
resistive during play, and also present management and educational
problems to parents, teachers and to professionals who deal with them.
Similar to what is said about learning disabled children in general, awk-
ward children possess hidden disabilities, problems that may only be-
come apparent when complicated motor tasks are expected of them.
Thus awkwardness among learning disabled populations presents still
another problem with which many learning disabled youngsters, and
those formulating programs for their benefit, must deal.
 Coordination Problems Among Learning Disabled Children 145

INCIDENCE
Poorly coordinated children are present in significant numbers in groups
of youngsters from which the obviously physically, mentally and sensorial-
ly handicapped have been identified and removed for special help. The
incidence of children evidencing poor coordination, according to various
estimates, ranges from 5% (Breamer & Gillman 1966) (Gubbay 1975)
(Henderson & Hall 1982) (Iloeje 1987), to 15% (Hoare & Larkin 1990, and
even to 20% of school populations, from which the obviously handi-
capped have been removed (Paine 1968) (Clements 1966). Their pres-
ence has been documented in Europe (Gubbay 1976) Asia, Africa, (Iloeje
1987), Australia (Hoare & Larkin 1991), and in North America. Thus
throughout the world it appears as though there is at least one awkward
child within most classroom settings containing at least 20 youngsters).
Thus motor awkwardness appears to be a pervasive problem among con-
temporary children and youth.

Gender Differences
It has been assumed for several decades that clumsiness is more prevalent
among boys than among girls (Henderson & Stott 1977) (Lazlo et al.
1988). However recent evidence suggests that this problem may be as
common among young females as among males (Short & Crawford 1984)
(Hoare & Larkin 1991). In the past a preponderance of awkward boys,
have been usually found among both experimental and clinical popula-
tions studied. However, this sex bias may have been due to the tendency
to refer boys, more often than girls, to remedial programs.

Motor Awkwardness Among the Learning Disabled

Contemporary data indicate that the incidence of motor disabilities within
dyslexic populations is usually greater than is expected within academical-
ly average groups. Brying & Michelsson found that 18% of a learning dis-
abled group they surveyed evidenced motor problems (1984). Bruininks
discovered a similar percentage of poorly coordinated youngsters among
a group of learning disabled children (1978). Klasen places the percent-
age even higher, finding that 49.2% of the dyslexic group she surveyed
evidenced visual-motor difficulties (1972). Jaklewicz after measuring a
population of Polish children with dyslexia, over a ten-year period, stated
that disorders of motor functions coexist with dyslexia in a rather constant
manner. Her findings indicated that not only are motor problems perva-
146 Bryant J. Cratty

sive in dyslexic populations, but also that coordination problems persist in

individual youngsters over an extensive period of time (Jaklewicz 1980).
In a study by Sudgen and Wann (1978) it was also found that higher
incidence of motor problems existed within a population of children
with "moderate learning difficulties" than is expected among children
without learning problems. They discovered that from 29—33% of the
learning disabled children they tested evidenced coordination difficul-
ties, as contrasted to the 5% of children with motor problems who are
expected within academically normal populations (Sudgen and Wanri
1987). In a recent cluster analysis by Miyahara (1992) it was found that
among a learning disabled population numbering one hundred and six-
teen boys and girls, over 60% evidenced either several motor problems
or a specific coordination difficulty.
Qualitative differences have also been found when contrasting the
motor characteristics of learning disabled, dyslexic youngsters to popula-
tions who are academically intact. For example, in a series of studies, Pe-
ter Wolff and his colleagues identified deficits in timing tasks (finger
tapping and the like) among academically deficient populations. (Wolff
et al. 1 984). They attributed these differences to neurological problems
among the learning disabled including either impaired hemispheric com-
munication, or functional difficulties within the left hemisphere (Wolff et
al. 1990). They assumed that these differences reflected timing problems
common both to reading and to executing relatively simple, rhythmic
motor tasks.

HISTORY & BACKGROUND

For centuries dramatic and obvious movement anomalies, observed in

both the brain damaged and among the emotionally disturbed, attracted
the attention of medical doctors and of scholars within emerging scientif-
ic-medical disciplines. Aurelous von Hohenheim, who lived from 1493 to
1541, was among the first within the Western World to describe the signs
and symptoms of a number of movement disorders. Included among his
writings are descriptions of actions he labeled 'choreas' (from the Latin "to
dance") consisting involuntary spasms seen in the face, trunk, and limbs
(Barbeau 1982). For the next four centuries other medical pioneers, with
increasing sophistication, explored the causes, symptoms and potential
cures of other movement disorders.
However not until the middle of this century has motor incoordination
among maturing children attracted much scientific interest. Scientific in-
 Coordination Problems Among Learning Disabled Children 147

terest in what was sometimes termed the 'clumsy child syndrome' has
been varied over recent decades. The pioneering efforts of Nicholas Os-
eretsky in Russia during the 1 920's signaled the start of this type of fo-
cus. The qualities of clumsiness evaluated subsequently were often
dependent upon performance demands and upon values attached to
physical prowess in various sub-cultures, and upon the orientation of the
professionals assessing motor inaptitude in children.
Since the 1 960's articles focusing upon the awkward child have ap-
peared with increased frequency in journals of pediatrics, neurology,
education and learning disabilities. In 1 975 three books focusing upon
the awkward children were published. Two had similar titles "The Clumsy
Child" (Gubbay 1975) (Arnheim 1975). A third book titled "Remedial
Motor Activity for Children" (Cratty 1975) also dealt with the identifica-
tion and remediation of poor coordination in children. Contemporary
work has illuminated the nature of neurological soft-signs, included both
sensory and academic symptoms prevalent among children with poor
coordination (Tupper 1987). A text dealing with Clumsy Child Syn-
dromes by Cratty (1995) also presents a comprehensive view of the
problems of physical awkwardness occurring in developing children and
youth.
A contemporary emphasis upon the early recognition of physical awk-
wardness in children as a medical problem has been evidenced by the
inclusion of this condition in standard neurological texts in the 1960's
(Walton 1966) (Brain and Walton 1969) (Ford 1966). Often this problem
has been categorized as a type of minimal cerebral dysfunction, or as a
type of neurological soft-sign, reflected in symptoms of motor incoor-
dination (Deuel & Robinson 1987).

Poor Coordination Among the Learning Disabled

Scholars have interpreted the significance of motor difficulties among

groups of learning disabled and dyslexic populations throughout the
years. On one hand, Critchley & Critchley (1978) proposed that that de-
velopmental dyslexia is due to cognitive disabilities which are "frequently
of constitutional origin" (page 7). Moreover these same authors suggest
that the incidence of motor disabilities within dyslexic populations is "en-
tirely coincidental," and thus (poor coordination) is 'apart from dyslexia'
(page 89). They concluded that "dyslexic boys are proficient at ball games,
while girls maybe able in needle work" (Critchley & Critchley 1978, p 92).
Numerous writers, in the early 1 950's began to promise that the iden-
tification and remediation of poor coordination in learning disabled
148 Bryant J. Cratty

youngsters will dramatically improve both school readiness and academ-

ic success. The titles of their books and articles often reflected these
cheery speculations, and included "How to Develop Your Child's Intelli-
gence," (Getman 1 952) and others (Kephart 1955). As a result, some un-
suspecting teachers, parents, and other professionals eagerly exposed
children to structured regimens of motor activity in attempts to improve
reading and other academic, perceptual and cognitive skills. Mostof the
time, however, the expectations and hopes these theories generated
have not been realized. However, the results of a critical survey by Ka-
vale and Mattson (1983) suggested that, (1) not only did well publicized
programs of motor remediation not significantly modify learning efforts,
including reading, but that (2) better classroom progress would have
been obtained through traditional applications of academic tutoringand
that (3) the motor programs applied did nothing to improve measures of
motor coordination. Other reviews of the literature have also concluded
that simply trying to remediate dyslexia through the application of motor
program will not succeed in modifying reading or other academic quali-
ties. (Critchley & Critchley 1978) (Myers & Hammill 1989). Reviews of
the currently popular sensory-integration approach to remediating aca-
demic-reading disabilities by both Lerer (1985) and Gottlieb (1987) also
point to the short-sightedness of attempting to remediate academic diffi-
culties with simply-applied sensory-motor strategies.

A Contemporary Viewpoint
Recent research should encourage professional workers to view physical
awkwardness with more precision, than was true in past (Miyahara 1992)
(Hoare & Lark in 1991). These data are also beginning to encourage the
formulation of symptom-specific remedial procedures. Some of the perti-
nent literature appearing during the past two decades, has begun also to
focus upon both poor physical coordination as a problem, separate and
independent of academic learning disabilities. Thus the use of motorinter-
ventions to modify a laundry list of academic difficulties, including reading
is becoming increasingly naive. Lastly newly developed imagining tech-
niques have begun to result in the identification of someof the neural sub-
strates underlying subtle coordination difficulties (Knucley etal. 1983).

The Present Focus and Contemporary Trends

This lecture is an effort to illuminate the causes, characteristics and educa-
tional ramifications of learning disabled youngsters with below-average
 Coordination Problems Among Learning Disabled Children 149

physical coordination. In the United States, during the 1980 and 1990's,
poorly coordinated children have become increasingly recognized as an
important sub-division of youngsters requiring special testing and services.
This recognition is reflected in legal—educational descriptions which guide
the diagnosis of all atypical children. The 1987 revision of the Assessment
Code, contained in the Diagnostic and Statistical manual employed by
psychologists and psychiatrists in the United States, contains detailed de-
scriptions of what are labeled, "Specific Developmental Disorders" (Axis
111). One is termed a "Developmental Expressive Writing Disorder"
(31 5.80), and a second a "Developmental Coordination Disorder"
(31 5.40) reflecting poor integration of the larger muscle groups.
It is believed also that the specialists in learning disabilities, and those
formulating curricula for the learning disabled, have important moral,
professional and legal obligations to assess and to attempt to rectify mo-
tor coordination problems frequently exhibited by the members of the
population they serve.

CAUSES AND NEUROLOGICAL IMPLICATIONS

One cause of poor coordination is some degree of oxygen deprivation

occurring at birth. All structures of the body are susceptible to hypoxic
injury prior to, or during, birth. However, most vulnerable are structures
within the central nervous system. Problems encountered by the prema-
ture infant, including short episodes during which breathing terminates,
results in hypoxic reactions, damage to the respiratory centers themselves,
and other functional problems such as a compressed or entangled umbili-
cal cord. Severe may cause death.
When oxygen deprivation to the brain occurs it is likely to influence
the type of damage incurred and also the developmental delays later en-
countered. For example, if oxygen deprivation occurs early during gesta-
tion, the deeper layers of the brain including the several centers,
controlling movement storage and programming, are likely to be in-
fluenced. If apoxia is encountered later in development, damage is likely
to be seen in the cerebral cortex, and thus associational-thought pro-
cesses are likely to be disrupted. However, cerebral damage within each
circumstance may be widespread and diffuse, or result in abnormalities
related to a more limited area (Towbin 1970).
Vascular accidents prior to, during or shortly after birth also cause mo-
tor difficulties ranging from the mild to the severe. These incidents can
include rupturing of blood vessels early in fetal formation and thus in-
150 Bryant J. Cratty

volve the deeper layers of the central nervous system. In contrast, those
occurring later during gestation of shortly after birth are likely to influ-
ence more superficial layers of the central nervous system. Near birth
the cerebral cortex acquires it venous system, and thus is susceptible to
damage due to one or more vascular accidents (mild infarctions).
As is true in the case of hypoxia, vascular incidents are not of all-or
none nature. Vascular accidents and incidents occur to varying degrees,
as is true of oxygen deprivation. The resultant neural damage due to in-
fractions may thus vary markedly. Marked and obvious disruption of the
motor systems occurs when these two problems occur in severe propor-
tions, while minor to moderate symptoms of clumsiness are encoun-
tered when these problems occur to mild degrees (Towbin 1987). A
sharp blow to the head is one cause of behavioral abnormalities which
reflects trauma to the central nervous system. If no penetration of an ob-
ject occurs these are usually labeled "closed brain injuries." Delineating
the precise manner in which behavior will be disturbed is not always pos-
sible upon knowing the location of the cranium which has received the
blow. Striking the head may thus have unpredictable outcomes. This un-
certainty of outcomes occurs because a blow can cause a shearing ef-
fect, in which surface neurons are scraped in ways that may cause
problems difficult to predict. Often swelling produced by a blow in one
portion of the brain may cause pressures in other parts, also producing
diffuse and/or unpredictable outcomes. Unilateral involvement occurs if
the child has been struck on the side of the brain. Movement problems in
this case appear on the side, opposite to that receiving the blow. Usually
the younger the child or youngster incurring head trauma, the more like-
iy post-trauma motor functions may be positively modified with remedial
efforts. A relatively small percent of learning disabled children, with mi-
nor, to moderate coordination problems, have suffered some kind of
head trauma.
Types of biochemical insults may also cause neural damage reflected
in poor motor coordination. One type of problem encountered in large
numbers of infants in the 1980's were the influences of drug ingestion by
pregnant mothers. These noxious substances include crack cocaine, dis-
cussed in the section which follows. Other abusive substances ingested
by pregnant mothers including alcohol, and nicotine can cause develop-
mental problems including motor incoordination (Deren 1986). Lead
poisoning, as well as exposure to asbestos may cause problems that are
reflected partly in motor incoordination and mental confusions in
executing recreational skills and self-care tasks.
 Coordination Problems Among Learning Disabled Children 151

The limited information that is available indicates that familial in-

fluences may also result in awkwardness in some children. In a study, in-
volving more than 53,000 women, sponsored by the National Institute of
Neurological Diseases and Communicative Disorders, conducted be-
tween 1959 and 1965, developmental parameters including motor coor-
dination were contrasted to variables that included family membership.
It was found that the probability of a child evidencing signs of neurologi-
cal dysfunctions, including motor incoordination, were 30% greater
when other peers also were delayed motorically. The familial relation-
ships extended also to linkages of moderate neurological dysfunctions
among cousins.
In the same study when the presence of motor soft-signs in forty twin
pairs were contrasted, the degree of predictability rose even higher (Ni-
chols 1987). Regehr and Kaplan (1988) also have found that motor inap-
titude when coupled with learning disabilities are apparently traceable
through families.
Numerous other types of insults to, and problems within the central
nervous systems may cause motor incoordination of either an obvious or
subtle nature. These include tumors of various types that are often the
result of little-understood inherited qualities. Tumors within the central
nervous system are of numerous kinds. Their type, size and location will
influence development in unpredictable ways. A tumor may cause an or-
gan to malfunction, and/or crowd neural structures thus causing prob-
lems by their bulky presence. Sometimes surgical and chemical efforts to
reduce tumor's effects results in unwanted symptoms including sensory,
cognitive and/or motor deficits.

SUB-TYPES

It is apparent that several sub-syndromes occur within the groups of

youngsters evidencing "The Clumsy Child Syndrome." It is purposed with-
in this section to identify and to describe the characteristics of the more
prevalent sub-syndromes among populations of awkward youngsters
among the learning disabled. This identification is believed important for
several reasons. The description of viable sub-syndromes should result in
more useful diagnostic and remedial guidelines being formulated, than
are presently available. Secondly, this analytical undertaking might serve
to stimulate needed research focusing upon awkward children among the
learning disabled.
The following sub-syndromes were formulated by consulting two
1 52 Bryant J. Cratty

types of information. The first source consisted of research studies. In

these, investigators employed factor and cluster analyses of perfor-
mance attributes, obtained from groups of awkward children (Miyahara
1992) (Hoard & Larkin 1991). Groupings of neurological soft-signs have
also been explored using factor analytic methods, and have provided
another source of objective data (Turner 1987).
Information was also derived from our own clinical observations and
upon the experiences of other professionals working with neurologically
suspect infants, children and adolescents within remedial educational
settings.

CEREBELLAR SYNDROME

Cerebellar functions in humans have been studied for decades. For exam-
ple, symptoms reflecting a moderately dysfunctional cerebellum have
been measured in late childhood and have been associated with low birth
weight by Lesny and others (1980). Cerebellar problems are thus likely
among numerous populations of developmentally delayed youngsters.
One of the main jobs of the cerebellum is to refine and smooth motor
programs, as they emerge from the central nervous system, and journey
to the muscle-collections that combine to produce smooth and purpose-
ful action patterns. The cerebellum also is believed by some as responsi-
ble for controlling and preprogramming various rapid automatic patterns
in which some muscle groups engage. These automated movements
may include the rapid throws (saccades) made by the eyes when read-
ing. Other times the eye jumps in this rapid manner when tracking fast
moving objects (moving more than about 50 angular degrees per se-
cond).
The groups cerebellar-motor symptoms seen in a child also may in-
clude tremors and inaccuracies of the larger muscle groups, as well as
hand-eye coordination difficulties. Problems controlling precise eye
movements are important when engaging in sports containing rapidly
moving objects and people, may also be caused by cerebellar dysfunc-
tions.
Larger parts of the cerebellum are devoted to controlling the precise
movements of the mouth, lips, and hands, as is true of the main sensory-
motor cortex. In contrast, smaller portions of the cerebellum mediate the
less precise movements of which the trunk, and lower limbs are capable.
This is an important principle to keep in mind, when considering the spe-
cific nature of various cerebellar soft-signs that awkward child manifest.
 Coordination Problems Among Learning Disabled Children 153

Among the main behavioral signs of some kind of cerebellar "involve-

ment" are unsteadiness and mild tremors. As only a portion of the cere-
bellum may be involved, in some youngsters the tremors may be seen as
regular low amplitude fluctuations only in the hands, or of the pencil
when drawing, and may not be apparent in the lower limbs. In other chil-
dren, unsteadiness is only evidenced in gait, or when attempting to bal-
ance. The presence of unsteadiness and tremors in both the upper and
lower parts of the body is most likely, however. Unsteadiness in the up-
per limbs may be seen as the child produces lines in which there are
marked by tremors, and unsteadiness while walking. Other problems in
hand-eye coordination may include dysmetrias, difficulties in making ac-
curate lines, and making reaching movements of exact lengths. Addition-
al problems can include a decomposition of rhythmic and fluid move-
ments, into disjointed and disconnected ones.
Other types of cerebellar symptoms include poor kinesthetic aware-
ness of limb location. This child, for example, may need to watch his or
her arm as it is drawn back in an overhand throwing motion, or it may
simply 'disappear' from the thrower's consciousness.
Scientific verification of the existence of a sub-syndrome of cerebellar
types' among groups of awkward youngsters may be found within the
date emerging from several studies of neurologically suspect children.
For example, an investigation by Ritter and his coHeagues (1970), it was
found that hopping tests frequently identified children with other neuro-
logical soft signs present, including problems when walking and turning.
Nichols' comprehensive factor analysis, conducted from 1959—1965, us-
ing data obtained from several thousand children (1987) also reflected
this syndrome. Nichols found that the inability to hop consecutively at
the age of 4 years, together with imprecise drawing efforts were both
predictive of the appearance of other symptoms later in life including hy-
peractivity in school settings. More directly to the point, associated signs
of clumsiness including measures of poor coordination and abnormal
gait. At the same time these two measures 'loaded' in the same factor as
signs of synkinesia (mirror movements) and other abnormal movements
(Nichok 1987).
Two recent cluster analyses conducted with populations of awkward
children further confirm the existence of this sub-syndrome. Miyahara
(1992) identified a sub-group within his data, that included with poor dy-
namic and static balance, coupled with deficits in ball-aiming skills. The
linkages described earlier in this section between visual accuracy and
balance, both attributes hypothetically mediated by the cerebellum,
154 Bryant J. Cratty

would account for this association between deficits in ball skills and bal-
ance within Miyahara data. Hoare and Larkin (1991) also identified a
sub-group of awkward children evidencing specific deficiencies in bal-
ance, and the absence of other pronounced motor coordination prob-
lems. This group constituted over 28% of the awkward children assessed
in their cluster analysis (Hoare & Larkin 1 991).

Hypotonic Syndrome
Children beset with the hypotonic syndrome, display levels of resting
muscle tone that are below average. This flaccid state may also occur in
the facial region, and in other parts of the body. For example a hypotonic
youngster may display a 'a sleepy look' as overly relaxed muscles lifting
eye lids, result in the eyes remaining half-closed even during waking hours.
Among children with this condition the stomach muscles may appear flac-
cid (ptosis) resulting in a "pot-bellied" look. The term benign hypotonia
has been used to describe this type of syndrome, indicating that the
condition is not progressive (Eng et al 1979).
One of the five sub-types identified by Miyahara's cluster (1992) evi-
denced hypotonicity and poor fitness, coupled by "fair coordination."
This was the fifth most prevalent sub-type within the population of learn-
ing disabled awkward children measured by Miyahara, and accounted
for almost 4% of the youngsters surveyed.
This condition is usually encountered first in infancy, as delays in the
assumption of various important stable and static positions are at-
tempted. During the past two years I have assessed and devised develop-
mental programs for three hypotonic infants ranging in age from 18—22
months who could not sit up unassisted. An additional two youngsters,
whom we have evaluated, were almost three years of age, and yet had
not pulled themselves to a standing position and thus had not begun to
walk. The overall physical health of these youngsters was adequate and
normal, nor did the condition seem to be progressive in nature. They ap-
peared similar to floppy rag dolls when attempting to sit unaided, to as-
sume a creeping position, or when trying to stand. Home-based
programs of infant stimulation were formulated, in which their parents
could participate.
The status of most young children evidencing below-average levels of
residual muscle tone, remains constant and benign, and they do not de-
velop more serious and progressive neuromotor problems later in life.
However in relatively rare cases hypotonia observed in a preschool
youngster may be a sign of progressive condition. In the factor analysis
 Coordination Problems Among Learning Disabled Children 155

by Nichols (1987), both the motor symptoms and personality character-

istics of the hypotonic youngsters are revealed. In Nichols' investigation,
a measure of hypoactivity loaded in the same factor as did tests denoting
"withdrawal' and "social-emotional immaturity" (Nichols 1 987). Nichols'
data confirms a compensation frequently seen among hypotonic chil-
dren, "learned helplessness." The hypotonic youngster of ten evidences
attentional deficits, but does not frequently engage in hyperactive be-
haviors. This type of 'dreamy' youngster often seems out of contact with
teachers, parents and peers. He or she may display periodical lapses of
both visual and cognitive inattention. Thus the hypotonic child is likely to
withdraw both cognitively and socially from both interaction in play and
in academic environments (Nichols 1987).

Tension Syndrome
Some youngsters labeled 'clumsy' display constant and excessively high
levels of muscle tone. In contrast to hypotonic children previously dis-
cussed, a youngster evidencing a tension syndrome displays signs of hy-
pertonicity while attempting skills, as well as when at rest. The tension
levels are raised when a skill becomes difficult for a child to execute. The
accompanying tension thus may compound struggles to execute complex
skills. This syndrome may also appear as a form of developmental dysgra-
phia. Furthermore, symptoms reflecting the tension syndrome, within
groups of awkward children, may represent mild to moderate forms of
spastic cerebral palsy.
This syndrome is often accompanied by excesses in overflow or
associated movements (synkinesia). When a hypertonic child is required
to engage in a forceful movement with the hands, the mouth may gri-
mace excessively and when vigorous jumping movements are executed,
the upper limbs may move and flex. Reaching movements are restrained,
because as they attempt to extend their arms toward objects, the smooth
elongation of the flexer muscles of the arm do not occur. Instead the bi-
ceps may become tense and inhibit coordinated extension. Basic re-
flexes may be exaggerated in strength when elicited (Nichols 1987).
Children exhibiting excess amounts of muscle tension typically evi-
dence hyperactivity. This includes exhibiting locomotor and manipula-
tive behaviors that are in excess of those desirable within a school
setting. Data from the study by Hertzig and Shapiro (1987) suggest the
consistent presence of hypertonic signs, within populations of prema-
ture children.
Unlike hypotonic children, who often seem to be in dream-like states
1 56 Bryant J. Cratty

for a good part of the school day, awkward youngsters evidencing a ten-
sion syndrome frequently leave their chairs in a classroom, grab for ob-
jects and swipe at other children who may pass in reach. The data from
the factor analytic study of neurological soft signs by Hichols (1987) con-
tains correlations between emotional fluctuations, short-attention span,
and muscular tensions coupled with impulsivity. Thus there is statistical
evidence that confirms the existence of the tension syndrome with ac-
companying attentional deficits and impulsivity.
Attempting to acquire printing and writing skills usually presents prob-
lems for this type of youngster. Learning to print letters may result in the
frequent 'overshooting' of a line, or ending point (dysmetria). This prob-
lem is sometimes 'solved' by the child trying to both start a movement
and to inhibit a movement(s) at the same time. Thus a great deal of ex-
cess tension may accompany efforts to improve graphic skills. Relaxation
training is often a helpful accompaniment to writing and printing lessons,
when working with this type of child.
Within a clinical setting, children evidencing 'tension syndromes' need
careful and patient attention. Frequent rests from tension producing
practice may be necessary. Breaks during which relaxation training, or
similar techniques may be applied, are often useful. At the termination of
motor skill lessons it may be necessary to apply additional relaxation
strategies to reduce their tension and to produce a positive emotional
state before they proceed home, or to other parts of a school program.

Dyspraxia Syndrome
Some awkward children have difficulties effectively planning and chaining
together series of sub-movements into smooth, well-integrated motor
skills. Their levels of muscle tone may not be excessively higher or lower
than average, nor do they evidence the unsteadiness reflecting some kind
of cerebellar involvement. Their problem may be reflected primarily in
poorly sequencing sub-actions of movements into whole skills. They may
be identified as dyspraxic.
Miyahara identified a sub-group among the awkward learning dis-
abled children he surveyed who evidenced poor "dynamic coordina-
tion." This was the third most prevalent syndrome within his population
consisting of over 30% of the total group surveyed, (Miyahara 1 992).
Two Australian researchers also found a group within the population
they measured evidencing poor motor abilities independent of per-
ceptually 'loaded' tasks. For example, these apparently apraxic children
did poorly in tasks involving complicated assembly work (Hoare & Larkin
 Coordination Problems Among Learning Disabled Children 157

1991). These youngsters constituted about 10% of the group surveyed

by these researchers "down-under" (Hoare & Larkin 1991).
After formulating a movement idea, a child afflicted with the apraxic-
dyspraxic syndrome may often act impulsively, rather than displaying the
self-control typical of neurologically more intact youngsters. These por-
tions of the frontal-associational centers may be also be deficit in these
youngsters. Hypothetically portions of the central nervous system of a
severely dyspraxic youngster has received an insult, either hypoxia or a
vascular accident, relatively early in prenatal development (Towbin
1987). This kind of neural pathology thus may have influenced the ade-
quate functioning of one, or more, of the several neural structures be-
lieved to inter-act in their control of motor programming, storage and
retrieval.
Symptoms of dyspraxia may also appear more markedly within some
parts of the body than within others. Deficits in motor planning skills
may, in various children, lie primarily in the hands, limbs, or when they
attempt to move their total body with accuracy through space. I recently
tested an eight year old boy who executed drawings resembling those of
a talented adult artist. However, when asked to replicate movements of
his limbs and total body he proved completely confused. The presence
of these specific types of limb and trunk apraxia, resulted in this boy evi-
dencing an extremely low self-esteem. He appeared severely depressed
because of the social abuse of peers consistently accompanied his ef-
forts to participate in playground activities. However, several months of
individualized instruction resulted in measurable improvement in his
ability to engage in sequenced playground tasks.
Dyspraxia in these children may also be reflected in speech-articula-
tion difficulties. Correctly sequencing the complex movements of the
tongue, lips, and other parts of the mouth, when forming word sounds,
may present profound problems for youngsters evidencing the 'apraxic-
dyspraxic syndrome.' Numerous neurological schedules assess speech-
articulation problems along with other movement-type soft signs (Ritter
1970) (Hertiz & Shapiro 1987). Speech pathologists often remark at the
unusual percent of children with gross motor problems who come to
them with speech difficulties. This problem has also been labeled oro-
apraxia, and buccofacial apraxia.
When working clinically with these type of children, it is important ini-
tially to expose them to various tests of motor-planning. It has been
found that motor planning deficits, and strengths, are task specific
(Cratty 1 989). When found deficits in these types of tests these children
158 Bryant J. Cratty

and adolescents should be taught multi-faceted skills using progressive-

part methods. For example, a complex skill should be first broken down
into parts, and after a single component is introduced and mastered, it
should be combined with a second, then a third part, until the entire skill
is mastered. Exposure of these children to impatient teaching and to ill-
prepared instructors, who demand the quick mastery of skills, are likely
to result in negative emotional outcomes. Gordon & McKinaly have also
written about strategies useful when working with dyspraxic youngsters
(1986).

Manual Graphic Syndromes

It is common to evaluate children whose main symptoms only reflect diffi-
culties with tasks requiring manual dexterity and/or who display problems
when attempting to draw letters and numbers. Two separate global manu-
al syndromes appear to exist. On one hand there are children whose fin-
gers fumble when attempting to button their clothes and who often drop
their forks and spoons while eating. Some of these, while holding their
pencils in a fist-like grip, will display average or above average abilities to
reproduce figures, letters and numbers.
In contrast, there are other children whose dexterity is adequate, but
whose graphic skills, including letter reproduction ranges from labored
to nearly absent. Indeed the factor analytic literature strongly suggests
that in adults there may be several more independent manual-dexterity
qualities or abilities within their overall 'movement profiles.' (Cratty
1975). Dysgraphia is frequently seen among the learning disabled. In a
learning disabled population we recently surveyed, this problem was
found to occur in from 30—40% of those assessed (Miyahara, Cratty, and
Goldman 1990). Dysgraphia, however, may also be unaccompanied by
other academic problems. For example, in a recent investigation of chil-
dren with writing and printing difficulties, it was found that about one-
half of the youngsters surveyed evidenced dysgraphia without the
presence of other learning disabilities (O'Hare & Brown 1989). Dysgra-
phia, unaccompanied by other academic difficulties, has itself been
labeled a 'specific learning disability' by Brown (1981) and others
(Myklebust 1973).
Among the contemporary classification systems proposed is that by
O'Hare and Brown (1989). They divide dysgraphia into two main catego-
ries. One is labeled specific dysgraphia, and includes three motor coor-
dination sub-groups, and a fourth reflecting spelling problems. A second
main classification they called non-specific dysgraphia. This classifica-
 Coordination Problems Among Learning Disabled Children 159

tion, they suggest, includes writing problems caused by cognitive and

experimental variables, difficulties typically seen within mentally handi-
capped and culturally deprived populations. In general, among dys-
graphic children one is able to identify specific sub-syndromes, roughly
corresponding to those listed within this section, including dyspraxics,
hypotonic and hypertonic youngsters, as well as unsteady tremorous
ataxic printing and writing.

VISUAL—PERCEPTUAL CLUMSINESS

There are numerous visual and visual perceptual problems that may result
in awkward motor behaviors. These problems may range from ocular-mo-
tor problems involving the erratic or inefficient movements of the muscles
moving the eyes, to severe retinal deterioration. In addition, the camera-
like eye may take a clear and accurate 'picture', but the child may not in-
terpret, and organize visual information well and quickly. This latter type
of confusion is often referred to as perceptual rather than a visual difficul-
ty.
Hoare & Larkin (1991) recently identified a sub-type within the popu-
lation of clumsy children they surveyed as evidencing problems in tasks
heavily loaded with visual—perceptual components. This sub-group, con-
sisting of 1 8% of the group they surveyed, had difficulty in "visually
loaded" tasks while evidencing average and above-average performance
in other motor skills.
Visual and visual perceptual problems interfere with accurate move-
ment because the eyes and motor systems are neurologically and thus
functionally intertwined in innumerable ways. Poor balance may occur,
for example, because the eyes are unable to focus well thus destabilizing
the child's space field. This type of problem may be seen when the
youngster is able to balance in a static position better with the eyes
closed, than when they are open. In these cases a confusing visual field,
when temporarily eliminated by closing eyes, permits the motor system
mediating balance to function better. In contrast, when some visually
and/or perceptually inadequate children attempt balance task with their
eyes open, below average scores may result. Problems causing unclear
vision may also inhibit accurate movement.
The presence of erratic (nystagmatic) eye movements, that may reflect
the presence of various visual pathologies, may also prevent a child from
intercepting and extracting information well from moving objects. Seri-
ous visual-neurological problems may also result in inability to intercept
160 Bryant J. Cratty

moving objects well. These can include the presence of a tumor, at any
one of several points within the optic pathways in the front of the brain
(the optic chiasm). These types of tumors may restrict the size of chil-
dren's visual fields, and thus prevent them from tracking balls through
the same wide arc, available to youngsters whose visual fields are normal
in size.
Accommodation problems, also commonly prevent children from fo-
cusing upon written work at a desk near the eyes. This problem involves
the inability of the ocular muscles to draw the eyes toward each other
and to focus at written work on the desk. Thus accommodation prob-
lems are likely to inhibit effective hand-eye coordinations needed when
learning to print letters. Most of these difficulties, however, are modifi-
able with corrective lenses.
Children whose visual systems are apparently intact may lack the abili-
ties to organize and to interpret important visual information. They ap-
pear to be beset with perceptual rather than with visual difficulties. This
quality also has been found to be multi-dimensional. Groups of tests eva-
luating visual perceptual (organizational and interpretational) skills are
applied to large groups of children and factor analyzed, a number of sep-
arate and independent qualities emerge (Smith and Smith 1966). These
included depth perception, the ability to fragment space (what is half-
way between you and the door?) and the ability to judge movement in
space. Thus it appears that deficits in innumerable visual and perceptual
problems, acting alone or in combinations, are likely to affect physical
skills in negative ways.

Mixed Syndrome
In addition to youngsters who evidence clearly definable sub-syndromes,
some awkward children display symptoms that make their precise classifi-
cation difficult. Thus the symptoms some awkward children display may
also cause them to be correctly labeled mixed'. For example, it is often
difficult to separate tensions and incoordination that may, because by
neurological causes, from difficulties arising an emotional overload, be
the result of continual task failure caused of poor motor planning abilities.
Ocular control problems may not only cause motor incoordination,
but also be part of a pervasive coordination problem arising from central
nervous system dysfunctions, also resulting in imprecise movements of
the larger muscle groups. Moreover, as Laszlo and her colleagues have
pointed out, motor clumsiness is often due to a combination of motor
incoordination, integration of process problems, and to deficits in moni-
 Coordination Problems Among Learning Disabled Children 161

toring kinesthetic sensory input (1985, 1988). Such subtle variables as

differences in leg length, poor foot mechanics or other postural-structur-
al problems can also influence motor functioning in youngsters.
Youngsters falling within this mixed classification may evidence a vari-
ety of coordination problems, reflected in virtually every motor task with
which they are confronted. Both Miyahara (1992) and Hoare and Larkin
(1991) identified sub-types who evidenced pervasive and consistent dif-
ficulties in all the tasks within the test batteries they employed. In Miya-
hara's investigation this sub-group consisted of 17% of the population he
surveyed. In an Australian population measured by Hoare and Larkin
(1991) the group of youngsters who were "consistently below average in
all tasks" comprised 1 9% of the group evaluated. Moreover, in both in-
vestigations even lower-functioning groups appeared in the data.

Overview
Acceptance of the validity of the presence of various syndromes suggests
that each poorly coordinated, learning disabled youngster, should be con-
sidered as unique. A knowledgeable evaluator should assume that few
general qualities and parameters exist, or that predictable correlations will
be obtained between tasks sampling various skill groupings. Moreover,
the presence of these various sub-types among learning disabled children
suggest the importance of instituting syndrome-specific interventions that
are carefully and developmentally planned.

SENSORY—PERCEPTUAL PROBLEMS

There are pervasive types of sensory and perceptual-motor difficulties that

are commonly found among various sub-categories of awkward children.
For example, it appears more likely that a child who is learning disabled
and awkward will display a larger number of perceptual deficits than will
be presented when an academically average or superior child is evaluated.

Body Agnosias and Dysgonias

The word 'agnosia' refers to a lack of awareness that may appear in vari-
ous sensory modalities. The term dysgnosia has also been used to denote
disruptions of sensory awareness, (Lesny 1980). Visual agnosi, as thus re-
fer to the poor visual perception of various stimuli, including word-blind-
ness, and reading problems. Auditory agnosias, in contrast, denote
auditory perceptual problems.
162 Bryant J. Cratty

There are also a number of 'body agnosias These deficits may involve
sensory-perceptual difficulties that children have when attempting to lo-
cate their bodies in space. Tactile deficits in the limbs and the fingers,
and also poor kinesthetic awareness of limb location and movement are
also contained within this general group of symptoms.
In the 1980's researchers began to link these sensory deficits occur-
ring in children to neural abnormalities. In one study, for example, it was
found that 50% of the youngsters, who evidenced dysgnosias, also had
abnormalities in various components of their central nervous system.
These structural differences included ventricular enlargement (Knuckey
et al. 1983).
The symptoms reflecting body agnosias may be inseparable from be-
haviors seen in youngsters diagnosed as evidencing dyspraxias of various
types. Thus confusions occurring when moving in space, and when se-
quencing task movements, may be attributed both to the presence of
dyspraxia, and also to the presence of dysgnosias. For example, if a child
has difficulties dressing himself/herself one observing clinician may iden-
tify the problem as a dressing apraxia, while another will state that the
problem reflects a body-agnosia (a type of somatoagnosia). Thus the
same, or a similar, behavioral deficit is likely to reflect the interaction of
both an agnosia and also of a specific type of apraxia.
There are measurable sub-components to various types of body agno-
sias and dysnosias. For example, digital agnosia, reflecting a lack of sen-
sory-awareness of the fingers and/or the hands, is composed of several
sub-components, including (a) deficits in the ability of the fingers to 're-
cord' sensations and obtain tactile information when objects (placed out
of view) are touched or stroked. This quality has been termed "stereog-
nosis or, if deficit, astereognosis (b) the ability of the child to identify fin-
gers when they are named verbally and (c) the ability to determine
where tactile stimuli are applied on one hand, when viewing the other
hand (Gerstmann 1940). Thus digital agnosia should be considered in
specific ways, and with reference to the test employed to evaluate differ-
ent sub-types.
For over one hundred years descriptions of deficits in the body image
may be found in the neurological literature. Initially the only descriptions
of agnosias available were those made among stroke patients (Obsers-
teiner 1881) (Luria 1966). During recent decades, however, agnosias
have been studied among maturing youngsters evidencing various devel-
opmental sensory and motor, problems. Initially a few, selected sensory
deficit were described among awkward children brought to clinics for
 Coordination Problems Among Learning Disabled Children 163

evaluation. Gradually the measures increased in number. Even now,

however, the majority of measures in examinations designed to assess
the presence of neurological problems in awkward children, evaluate
motor rather than sensory qualities (Tupper 1 987, Appendix).

SpataI Agnosias
General spatial agnosias refer to problems youngsters may have when at-
tempting to transport their total bodies through space with accurate se-
quenced movements. Difficulties are encountered by youngsters
evidencing this type of problem, when trying to move around the furni-
ture in a room, or when attempting to pass between classmates and
school desks. The bumping that may occur among peers may result in
awkward children experiencing social problems.
The remediation of, and accommodation, to this type of problem may
involve both communicating an understanding of the problem to the
child's caretakers, and helping the child understand his or herproblem in
clear terms. The presence of these spatial confusions should not be inter-
preted by parents as reflecting their off-spring's ignorance, or lack of will-
ingness to respond correctly to directions. Rather both the child and
parents should recognize the presence of the problem and should ac-
commodate to it in various ways. For example a series of directions, to
"go up stairs and to put on a red jacket," should be made shorter and
simpler. Most of the time partial directions should be given at first.

Tactile Agnosias of the Body

In addition to deficits in the heurological mechanisms mediating the men-
tal-spatial maps needed to move the total body through space, are prob-
lems reflected in the poor tactile awareness of the body's surfaces. Tests
to ascertain the sensitivity of the various surfaces of the body often consti-
tute parts of neurological evaluations. For example, a sub-test assessing of
two-point discrimination is often employed. This involves determining
how closely two points may be placed together and touched to various
body surfaces, before they are perceived by the child as a single touch-
point. At times, the clinician-physician may simultaneously stroke both
sides of the body in order to determine possible differences in tactile sen-
sitivity. If differences are found they have important diagnostic signifi-
cance, including the possible presence of tumors, and thus these
symptoms should be interpreted by those with appropriate medical back-
grounds.
164 Bryant J. Cratty

Limb Agnosias
In clinical practices, dealing with awkward children, it is common to en-
counter young clients who evidence the inability to locate their limbs in
static positions. Furthermore they also have difficulties when attempting
to kinesthetically monitor the movements of their arms and legs. When
throwing a ball, for example, such youngsters may keep their throwing
arms in front of their bodies. Poor kinesthetic acuity measured in limb
positioning, and in movement tasks among awkward children has been
verified in data from studies by Hulme and his colleagues (Hulme et al
1987), by Smythe and Glencross (1986) and by Judith Laszlo and her col-
leagues (Laszlo et al. 1980) (Laszlo 1985, 1988).
When attempting to remediate this kind of problem, it is often neces-
sary to augment kinesthetic input, with tactile stimulation, and with visu-
al information. For example, when teaching a child to throw, a mirror
placed to the side may prove a helpful teaching aid. The throwing arm
may thus be viewed as it is drawn behind the thrower's line of vision, If
the problem is severe, tactile input may be helpful. The arms may be
gently stroked or rubbed in order to afford more information as to their
location and volume. Children whose movement problems include cere-
bral palsy have traditionally been exposed to this type of tactile interven-
tion. Foot placement when attempting various locomotor tasks, such as
skipping and hopping, may be assisted if templates are placed on the
ground, into which the feet may be placed.

Digital Agnosias
Digital agnosia is the poor awareness of the location and tactile propri-
eties of the hands and fingers. There has been a long history of interest in
this problem, Digital agnosias include several sub-types. These include
problems reflected in tasks assessing sensitivity to touches received by the
hand. Difficulties in determining the shape, texture and shape when
touching or handling objects reflects another type of digital agnosia,
sometimes termed astereognosis. It has been found in several studies that
awkward children, when compared to normals, exhibit less tactile sensi-
tivity in the hands (Kinnealey 1989), and also receive less accurate in-
formation when both touching and handling objects with their hands
(Haron & Henderson 1985).
Gerstmann identified digital agnosia as one of three problems, within
a triad of symptoms, including difficulties in math (acalculia) and body
image deficits (Gerstmann 1927). Difficulties in carrying out simple
 Coordination Problems Among Learning Disabled Children 165

mathematical operations is associated with digital agnosia, some have

suggested, because these youngsters have problems using their fingers
as counting implements when gaining initial quantitative concepts
(Strauss and Werner 1938).
In a recent study my students and I found significant positive cor-
relations between measures of hand sequencing and mathematics abili-
ties, confirming the possibility of a sub-group of children evidencing
Gerstmann's syndrome, within learning disabled population evaluated
(Miyahara, Cratty and Goldman 1 990). In other studies by Lord &
Hulme (1987) and by Hulme and his colleagues (1982) it has been
found that clumsy children as a group are likely to be measurably defi-
cient in their ability to obtain accurate tactile-kinesthetic information
about the lengths and shapes of various objects when they are in-
spected manually.
Benton (1959) and others have formulated direct measures of finger,
or digital agnosia. Essentially these usually consist of asking a child to
identify which fingers are touched or stroked by an examiner, on a hand
that is kept out of view of the child. At times the identification of the fin-
ger touched is made verbally and at other times the child is asked to
move the finger, or fingers, involved. In the second case, a movement
quality probably influences the scores obtained.
In real life situations, a child afflicted with this kind of finger insensi-
tivity may experience a number of difficulties. I recently tested a six-
year old girl, who while scoring high on tests of intelligence, was eating
with her hands, rather than with table utensils, due to the presence of a
severe case of digital agnosia. Often children with digital agnosias, use
a fisted grip on their pencils while writing, they gain so little tactile in-
formation from their pencils when they are held in the usual way. At-
taching four fingers to the pencil thus afford them more tactile-sensory
information, than what is gained if the pencil or pen is be held in the
traditional way.
Children with signs of various types of digital agnosia often avoid
making small models. They also find typing their shoes difficult or im-
possible. They may fumble when attempting to use zippers, or buttons
on their clothing. Catching balls can prove difficult as they obtain late
and inaccurate information from the missiles as their hands contact in-
coming balls. They may also be fearful of climbing playground appara-
tus as they are unable to feel the bars in their hands when attempting to
grasp them.
166 Bryant J. Cratty

EMOTIONAL ACCOMPANIMENTS
Those studying and chronicling the characteristics and habits of awkward
children have been virtually unanimous in the observation that various
emotional problems accompany physical inaptitude. In many ways these
are similar to the problems usually found among the learning disabled,
and reflects compensations for feelings of low self-esteem. It seems logical
to assume that negative social feedback and poor self-assessments result-
ing from the inability to write well in a classroom, coupled with poor play
skills, will likely result in lowering both awkward children's and learning
disabled youngster's self-esteems. Available evidence from contemporary,
data-based studies is beginning to confirm this hypothesis.

Data Based Evidence

In one type of study, comparisons have been made between the self-con-
cept of children labeled clumsy, in contrast to how physically average chil-
dren report feeling about themselves. In an investigation of this type
conducted by me and post-doctoral students several years ago, a ques-
tionnaire-type self-concept test was used containing questions reflecting
children's feeling about their appearance and physical ability. The test was
originally constructed by Dale Harris and Ellen Piers (1964).
In four of the twenty questions tendered to the 222 male subjects, dif-
ferences were found between the two populations contrasted (Cratty et
al. 1 972). The awkward boys reported, more often than did the psychi-
cally adequate boys, that they were sad most of the time, that they did
not believe themselves strong, and that they would rather watch than
play games. A significantly larger percent of the awkward boys also re-
ported that reading was not easy for them. This final finding perhaps re-
flects the presence of a significant percent of boys with learning
difficulties often found within populations of awkward children.
A student and I recently followed up this 1972 investigation with
another, using a highly similar questionnaire (Dalrahim & Cratty 1990).
Eighty-three awkward boys, averaging 6.3 years of age, were polled rela-
tive to the feelings they had about themselves, and how they felt about
their physical appearance and ability. These were children, whom we
had evaluated during the past thirty-six months at our clinic and aver-
aged delays of from 1 to 1 .5 years in physical coordination. The scores of
1 7 awkward girls were used in the same study, using the same question n-
aire. They averaged 6.5 years of age, and also were delayed physically
from one to two years. Of the twenty questions there were marked dif-
 Coordination Problems Among Learning Disabled Children 167

ferences in the percent of low-self-concept responses of awkward chil-

dren obtained in the 1990 study contrasted to the response of normal
subjects in the 1972 study (Cratty et al.).
In a second type of investigation, comparisons are made of the motor
competencies of children within various atypical groups. Including in
these have been groups of children labeled learning disabled, the mildly
and moderately retarded, and the emotionally disturbed. An example is
a study by D.H. Stott and his colleagues (1972) in which comparisons
were made of children evidencing varying degrees of emotional malad-
justment based upon their scores from The Bristol Social Adjustment
Guide (Stott and Marston 1971). Stott found that the emotionally dis-
turbed population identified, was over represented among awkward chil-
dren. Hostility scores were found to be closely associated with motor
impairment, as were scores reflecting the tendencies to both over-react
to the environment, and to under-react and behave in overly passive
ways in social situations. Stott found that 'inconsequence' (failure to in-
hibit impulses) was the quality most highly associated with motor impair-
ment. The scores Stott obtained from the Bristol Social Adjustment
Guide also correlated with mean scores from the tests of motor impair-
ment administered.
Summarizing this work, Stott pointed out that three times as many mal-
adjusted children, compared to well adjusted youngsters, were motori-
cally impaired: And likewise three and a half times as many motorically
impaired youngsters, as compared to motoricaUy normal children, were
maladjusted (Stott et al. 1976).
The data from other, more contemporary, studies by Hulme and his
colleagues (Hulme et at. 1982) (Abbir et al 1978) and Henderson and
Hall (1982) also indicate motor ability tests can statistically discriminate
between groups of emotionally normal youngsters and groups of young-
sters evidencing various psychiatric syndromes. Data from additional in-
vestigations, including those by Van Rossum and Vermeer (1990) and
Ka!vergbor and his colleagues (1990) and others (Henderson et at. 1989)
also indicate that there are strong links between physical awkwardness,
low self-esteem, and social problems.
Factors analyses have also been conducted containing tests reflecting
both emotional qualities and movement qualities, including tests of coor-
dination and motor 'soft signs.' For example, in a study by Nichols
(1987), tests of hyperactivity, emotional stability, and attention span
loaded in a factor containing scores from two drawing tests. Thus the
168 Bryant I. Cratty

overall picture from this and similar studies is that motor inaptitude likely
causes various symptoms reflecting emotional upset.
The relationships between emotional instability and motor impair-
ment may be circular. Stott, for example, suggested that the interactive
relationships he found were due to the presence of general types of neu-
rological impairments that may have influenced both motor and emo-
tional qualities in the youngsters he evaluated. The correlations found in
the studies that have been reviewed, thus require close scrutiny in order
to determine possible causal relationships present, and the direction of
the causation.
Data from a few studies are now beginning to illuminate the possibility
of modifying emotional states by exposing awkward children to remedial
programs. In recent work by Laszlo and her colleagues, for example, di-
rect evidence was obtained of 'dramatic' changes in social—emotional
behaviors occurring among children exposed to a program, that also
produced parallel and positive changes in their physical skills (Laszlo et
al. 1988).
Most encouraging, however, are the recent appearance of longitudi-
nal studies surveying, not only motor characteristics, but also the emo-
tional states of youngsters assessed during several testing sessions taking
place throughout the formative years of life. These studies are obtaining
evidence obtained during significant time periods within the lives of the
young subjects studied. In one of the first of these it was found that,
while some awkward children improve overtime, many continue to have
difficulties, of several types, well into their teens (Gillberg & Gillberg
1989).
A comprehensive, longitudinal study was published recently by Anne
Losse and her colleagues. They compared measures of emotional health
and physical coordination, obtained from thirty-two youngsters at both
their sixth and sixteenth years of life. They found strong evidence that the
youngsters surveyed continued to have motor problems, attracting the
attention to those attempting to teach them motor skills during this entire
decade of their lives. During the several testing sessions necessary to
complete this study, it was also observed that many displayed "intense
personal feelings of failure" throughout this ten year period.
It was concluded by Losse and her helpers, that clumsiness is not a
benign disorder confined to childhood, but rather that awkwardness
continues into the teens. Their data also made it clear that persistent and
measurable evidence of motor ineptitude during the years the study
took place, was accompanied by feelings of social inadequacy among
 Coordination Problems Among Learning Disabled Children 169

most of the youngsters taking part in the study. However they also ob-
served that among some subjects who had been extended continuous
and effective parental support, symptoms of poor emotional health were
significantly reduced, and in some cases apparently eliminated (Losse et
al. 1991).
The available data from both correlative and longitudinal investiga-
tions thus strongly suggest that motor ineptitude both causes, and is ac-
companied by, low self-esteem and associated social adjustment
problems in many children and adolescents for significant time periods
during their formative years. Motor task performances constitute con-
crete, and observable, measures of competency, out of incompetency. A
youngster who cannot perform well thus sees vivid evidence of his or her
failings, and concurrently receives negative social feedback from observ-
ing peers, parents, and teachers. Thus both self-perceptions and the so-
cial judgements of others combine to lower the self-esteem of many
awkward children and adolescents.

Clinical Observations of Compensations, and Avoidance Strategies

A number of compensatory behaviors reflecting inadequate social-emo-

tional adjustment are likely to be exhibited by awkward children. Parents,
professions in clinics, and teachers are among those whose best efforts
are often thwarted by these, often abrasive, ways in which awkward chil-
dren act. These behaviors are expressed, and the forms they take are both
important to consider, when assessing and providing programs for chil-
dren with coordination problems.
Engaging in these strategies serve several important needs on the part
of a clumsy youngster. (1) A compensation sometimes reflects the child's
attempts to totally avoid situations in which physical performance will be
required, (2) in another group of behaviors that are seen within perfor-
mance situations the child has not been successful in avoiding. Thus
while on the playground the child finds ways of actually not participat-
ing. (3) Still a third type involves ways clumsy children have of modifying
both their own performance and performance demands so that they
have a chance to succeed, but on their own terms.
Often an awkward child will engage in several of these avoidances—
compensations, in quick succession, or at different times throughout a
single day. A compensation or compensations may be selectively used
when an awkward child is confronted with specific demands made by
adults, children and by various situations encountered. That is why many
youngsters will learn to carefully match a specific compensation to van-
1 70 Bryant J. Cratty

ous demands and stresses. It is typically found that each child favors one
or more of these compensations, and consistently relies upon them.
Some of the more common of these compensations are as follows.

School Phobias

Some poorly coordinated children may attempt to avoid school atten-

dance completely. They may do this for various reasons, including the
knowledge that they must take a fitness test in their physical education
class that day. Upon arising in the morning their effort to avoid school may
range from claiming illness, to 'throwing' temper tantrums. Their protesta-
tions may even be accompanied by measurable medical symptoms. They
may become nauseous when contemplating their school day, and accom-
pany these feelings with pleas to remain at home.

Learned Helplessness, and Infantilization

One of the most pervasive, and potentially harmful, compensations in-
volves the display of learned helplessness. Infantilization may be partly the
reflection of inappropriate caretaker behaviors, including the tendency of
some mothers and fathers to unknowingly reward "babyish" behaviors. In-
fantile behaviors arise from the fact that developmentally delayed children
often are subtly rewarded for their incompetence and inabilities to per-
form physical tasks well. The problem can also stem from an attitude,
adopted by the clumsy child, that most of what he or she attempts will
likely be unsuccessful. Thus they give up trying when confronted with
physical performance situations. If not encouraged by caretakers to try to
accomplish various motor task, over time helpless feelings become more
pronounced.
Symptoms within this general pattern of helplessness include display-
ing immature play patterns, and a disinclination to attempt or to persist at
motor tasks. These symptoms may even include delays of speech and
language. Infantile speech patterns are common among children who
have learned to be physically helpless. Signs of social and emotional im-
maturity displayed by an infantilized child may include frequent temper
tantrums, thumb sucking and similar behaviors that are not age appropri-
ate.
This pattern of behavior, if continually reinforced, will persist into
adolescence. Parents who continue to refuse to demand mature behav-
ior and performance will likely produce psychologically and physically
 Coordination Problems Among Learning Disabled Children 1 71

helpless teenagers. It is striking to observe these symptoms evidenced by

some adolescent learning disabled adolescents, for example.
The answer to this problem is usually intensive family therapy, so that
the mother and other caretakers are provided a mirror in which they may
view the ways they are rewarding, and thus maintaining, their offspring's
helpless and ineffectual behaviors. After gaining an awareness of how
their parenting practices influence their children, attempts would then
be made to modify these behaviors. However, often 'selling' the need for
such therapy is a task that professionals contacting parents are not al-
ways able to accomplish.

Comedic Behaviors and Other Types of

Compensatory Verbalization
Within play situations, the awkward child runs the risk of not been not-
iced. Being overlooked may appear to such children to be a form of pun-
ishment worse than receiving ridicule. Thus the uncoordinated youngster
often makes an effort to make the other children know they exist. One
strategy is to use an excess of verbal behaviors at play, and in other situa-
tions. These verbal behaviors may include (1) A constant attempt to be
funny, by engaging in excess comedic behaviors (2) Compensatory brava-
do, consisting of statements that express an overly self-confident demean-
or, "1 can make the Olympic Team!!", (3) Constantly voicing statements
that have nothing to do with a play situation, and (4) verbal preoccupation
with the rules, acting like a 'playground attorney.'
The content of hyperverbalizations varies. This excess chatter may
consist of persistent attempts to joke and be funny, including making fun
of the play situation and of other children. At other times this hyperver-
bal behavior consists of intellectualizations, about the skills required or
about other aspects of the games. Still another focus of this chatter may
be upon rules and their interpretation. In this latter case the awkward
child may sound like a youthful attorney, while engaging in sophisticated
arguments about scores, rules and the like. This type of verbal behavior
thus may also effectively block requirements to exhibit physical skills in
the games confronting the youngster.

Aggression
Lacking adequate play skills, awkward children sometimes engage in ex-
cess physical and/or psychological aggression against others. Sometimes
this aggression appears in the form of verbal abuse, or even of obesities
1 72 Bryant I. Cratty

directed toward peers. At other times aggression may consist of simply

chasing weaker or younger children around the playground. At still other
times direct physical aggression is engaged in. Case studies of young
adults who have evidenced marked sociopath behaviors often contain
scenarios of how, as children, they lacked adequate play skills and thus
began to take out their frustrations in the form of aggressive vengeance
against others.

MOTOR COORDINATION PROBLEMS AMONG

THE LEARNING DISABLED

Within the past decade, several studies have been conducted focusing
specifically upon the motor abilities, and their meanings, among learning
disabled children. For example, Denckla and her colleagues (1985), ex-
plored possible relationships between dyslexia, attention and motor profi-
ciency, and concluded that there were various sub-groups within learning
disabled populations, including those with and without attentional and
motor problems. In this same study it was also found that the tests of mo-
tor qualities they employed, including measures of synkinesia (overflow),
and of rapid-repetitive rhythmic movements, were more likely to predict
hyperactivity in children than were measures of specific learning disabili-
ties they obtained. Most important, their data suggested to them that
treatment outcomes may be different for the various sub-groups. Outcom-
es seemed to depend upon the presence of various combinations of
learning disabilities, hyperactivity and of types of motor incoordination
measured within each sub-division.
In two other factor analyses by Nichols (1978) and by Ayres (1972) it
was found that motor coordination and sensory-qualities 'loaded' in fac-
tors separate from those containing motor coordination items. It is inter-
esting to note however, that Ayres then proceeded to formulate and
promote a program of sensory-integration in which motor-sensory expe-
riences were advanced as producing change in a variety of academic
and sensory-perceptual processes. Moreover Ayres work has been re-
cently criticized for the capricious manner in which factors were labeled
within the various studies she carried out from 1965 and 1987 (Cum-
mins 1992).
The most reasonable contemporary viewpoint thus seems to be that
motor development programs should be one, of several parts, of curricu-
la for learning disabled youngsters. However, simply exposing a young-
ster with learning disabilities to sensory-motor experiences will do little
 Coordination Problems Among Learning Disabled Children 1 73

to modify academic competencies (Kavale 1987) (Gordon & McKinlay

1989) (Lerer 1983).
The data from investigations conducted at Landmark West from
1989-1992 have provided useful information about the motor abilities
and disabilities of learning disabled children (Cratty, Miyrahara & Gold-
man 1991) (Myrahara & Cratty 1991). As a group the youngsters in these
studies displayed motor coordination qualities inferior to current devel-
opmental averages.
These investigations also produced several findings useful to those
planning school programs for this type of population. For example, it ap-
pears that learning disabled girls may present special problems when
confronted with physical activity and physical education. They may lack
both motor activity capacities, and also harbor extremely negative feel-
ings about how they both look and function in motor skill situations. The
data revealed that the females were even further behind norms, than
were their male classmates, when measures of coordination, fitness—
strength, and self-concept were averaged. It appears that special atten-
tion would thus be paid to special needs of learning disabled girls when
programming for physical improvement. The data we and others have
obtained related strongly suggest that many learning disabled youngsters
are not happy with their body's appearance and with the sports skills and
fitness they are able to exhibit.
The data also suggest that important sub-groups are present both with-
in populations of awkward children and also within groups of the learn-
ing disabled (Lubs et al. 1991). On the basis of this data it appears that
learning disabled children may be divided into at least four sub-groups,
relative to physical competencies. These include one group which is rela-
tively free of motor problems, and indeed may be able to compensate
for academic deficiencies through vigorous and sustained participation
in recreational sports, and in related activities.
A second sub-group seems to consist of individuals who evidence mo-
tor planning problems along with academic difficulties. There is recent
evidence that this sub-type may be pervasive within family complexes
(Regehr & Kaplan 1 988). Rie also refers to the problems learning dis-
abled children have executing complex serial skills (1987). A third group
may evidence adequate skills and fitness, but require a longer period of
time to acquire complex skills because of the presence of dyspraxias of
various kinds.
Still another sub-group of the learning disabled may be able to learn
skills reasonably well, but lack the muscular and cardiovascular fitness
1 74 Bryant J. Cratty

and the coordination needed to fully and vigorously participate in sports

and games. This fourth group seems to possess physical capacities that
remain underdeveloped, because they apparently lack the motivation to
participate in vigorous physical activities.
Important to consider is the lack of age-trends in the motor planning
scores obtained in these studies. This finding suggests that basic prob-
lems in sequencing may persist in learning disabled populations through-
out life. If this information is confirmed in subsequent investigations,
older learning disabled children and adolescents should also be patiently
taught new and complex skills, as is true when dealing with younger chil-
dren within this type of population. Longitudinal studies, also substanti-
ate the persistence of motor problems, and neuro-motor soft signs,
among groups of clumsy children for as long as ten years (Losse et al
1987).
Overall this and similar data suggest that motor coordination prob-
lems are an additional difficulty with which many learning disabled chil-
dren must contend. Thus helping the learning disabled to improve
physically is an important goal to be pursued along with strategies in-
tended to elicit academic competencies.

EDUCATIONAL STRATEGIES FOR IMPLEMENTING CHANGE

A question frequently asked by both parents and teachers who observe

youngsters evidencing clumsiness is, "Can anything really be done to
change a child's coordination?" Professionals formulating programs for
awkward children should be prepared for these questions during parent
conferences following evaluations. They should attempt, furthermore, to
offer the best answers possible, by referring to the best available data and
to expert opinion. Several variables should be taken into consideration
when formulating an answer. These include the age and emotional state of
the child, the degree of awkwardness present, and the skills in which im-
provement is needed.
A comprehensive study used "neurologically impaired" children as a
sub-population. It was completed in 1968 by C. Lawrence Rarick and his
then doctoral student Geoffrey Broadhead (Rarick & Broadhead 1 968).
Their study explored the possible influence of several variables upon
change in a number of physical abilities. Two major subject populations
were employed including a group of 206 "minimally brain damaged"
boys and girls, placed within two age groups, one a younger group of six
to nine year olds, and a second group ranging from ten to thirteen years
 Coordination Problems Among Learning Disabled Children 1 75

of age. A second group consisted of 275 "Educable Mentally Retarded"

children were divided into the same two age groups.
Several variations of instruction were applied in this study, thirty—five
minute daily, five days a week, for a twenty week period. These included
one group taught whose members were physical education individually,
and a second group instructed as a small class. Two control groups were
also present. One of these remained in their regular physical education
classes. The second control group was given art instruction in order to
control for the possible effects of special attention upon the changes re-
corded in the two experimental populations.
The results of Rarick's study were highly promising. For example it was
found that significant changes in most of the motor performance tests
were recorded by the experimental group exposed to an individualized
program. The children labeled minimally brain damaged (who might be
labeled hyperactive-learning disabled today) recorded significantly
greater changes in motor abilities than did the retarded youngsters. The
older male children with minimal brain damage improved more in overall
motor abilities, than did the girls, or groups of younger children.
In 1972, my colleagues and I completed a study in which we con-
trasted the possible improvement in motor abilities measured in a group
of twenty-eight awkward boys and girls (7—12 years of age) with whom
were working at UCLA. Their scores were contrasted to motor abilities
measured in a control group of learning disabled children from a local
school district. The control group engaged in a regular program of physi-
cal education, while the experimental group came to the University
twice weekly for one-hour programs of individualized work in motor
skills and coordination. The program included work on drawing-printing
skills and also contained the teaching of various gross motor skills. The
children in both groups were evaluated initially, and at the end of a five
month period. The scores of the trained subjects, were matched and
contrasted by age and sex to those of the controls (Cratty et al. 1 972).
The data also offered some support for the efficacy of a special pro-
gram of motor development. Overall the percent of improvement was
over 2.7 times greater by the experimental group, than was true among
the control group when the average scores, reflecting percent of in-
crease, from the battery of gross motor tests were contrasted. Additional-
ly the mean scores from a figure drawing task also evidenced more
improvement among the experimental subjects (14.4%), than was re-
corded in the data from the control group (1.1%).
Additionally the progress in various types of gross motor tasks re-
1 76 Bryant I. Cratty

vealed that the most marked improvement through training, occurred in

balance, locomotor agility, and the catching of balls. Less improvement
was noted in scores denoting the identification of body parts, and in
gross agility (ascending quickly from a back lying position, and copying a
four-part movement of the total body). Encouraging was the finding that
the ability to execute complicated geometric figures, adding one part at
a time, was highly modifiable through training.
The data was also analyzed to determine within what age ranges the
percentage of improvement was most apparent. As can be seen, the im-
provement among the fourteen younger children from 7—9 years, was
more marked than among the fourteen children whose ages ranged from
10—12 years of age.
There are indications in the data that it is not inevitable that possible
changes in physical coordination will occur through maturation. The
controls, even though exposed to a regular physical education program,
regressed in some ability areas. Similar regression in physical attributes,
as a function of disuse, has been found in a more recent fitness study
among the learning disabled (Cratty and Delrahim 1992).
Within recent years, both clinicians and researchers have suggested
strategies for remediating dyspraxia symptoms in children (Gschwend
1988) (Gubbay 1975). Seaman and DePauw, for example, listed twenty-
one activities purporting to remediate fifteen signs of dyspraxia in chil-
dren. However their suggestions were not accompanied by research
data substantiating their worth (Seaman and DePauw 1982).
Gschwend (1988) also purposed a program for dealing with dyspraxia
in children. This program included music and art therapy, playing chess,
and other types of cognitive training lab&ed "will training." Gschwend's
suggestions thus appear to constitute a more global approach to general-
ized cognitive-motor strategies than was true in the more skill-specific
program suggested by Seaman and DePauw (1982).
In a recently completed study, it was significant improvement in up-
per-body strength that was elicited by exposing learning disabled chil-
dren to a fitness program (Delrahim & Cratty 1991). In this same study,
marked improvement in strength was also found among sub-groups of
learning disabled girls, and pre-adolescent boys and girls. Most interest-
ing, however, was evidenced that control populations who did not par-
ticipate in training recorded decrements in fitness and strength,
measured over time periods lasting from six to twelve months in dura-
tion.
Longitudinal studies which began to appear in the late 1980's corrob-
 Coordination Problems Among Learning Disabled Children 1 77

orated the persistence of coordination problems, along with social-emo-

tional difficulties, among groups of motorically deficient youngsters
(Gillberg & Gillberg 1989) (Losse et al. 1991). In the study by Losse
(1991) for example, it was found that motor problems, reflected in the
presence of motor soft signs, were present not only at the age of six
when her thirty-two subjects were first evaluated, but were also seen in
evaluations conducted ten years later. While some of the children sur-
veyed over time had made progress, the majority had experienced stress
from teachers, and also negative social pressure from peers during their
childhood and adolescent years. Gillman and Gillman (1989) have also
found that while some of their subjects had improved over time, many
had continued to evidence coordination difficulties.
The data from these investigations, and from earlier studies, suggest
that remediation of motor difficulties may take place, but only with the
institution of effective, individualized programs, that are carefully staffed
and planned and developmentally precise. Moreover the information
obtained in comprehensive effort by Losse and her colleagues in Lon-
don, suggests that only with sustained and effective parental support are
poorly coordinated youngsters likely to weather the social and academic
'storms' the are likely to encounter during their childhood and adoles-
cent years (Losse 1991).
There have been several experimental studies conducted, whose au-
thors attempted to determine if the reduction of motor soft-signs, includ-
ing indices of poor coordination, occurs after exposing children to
mediation intended to improve attention span and reduce hyperactivity.
The findings from these studies have been mixed. Skekim and his col-
leagues conducted a study to determine whether soft-signs were re-
duced as the results of medication (3-methoxy—4—hydroxy—phenethyl-
eneglycol, norepinephrine metabolite). The study was not well con-
trolled, however. The reduction of soft signs noted may have been due
not only to the effects of medication, but also because the subjects ma-
tured during the relatively long time interval during which study was con-
ducted (Skekim et al. 1979).
Lerer and Lerer (1976) studied the effects of methylphenidate upon
forty hyperactive children who exhibited three or more soft-signs. Six-
teen of the twenty children in the experimental group evidenced a re-
duction of soft-signs, in contrast to no seductions among children in the
twenty-member control group. However the study suffered from several
methodological problems including the use of neurological evaluation
of questionable objectivity, and the lack of adequate controls.
1 78 Bryant I. Cratty

In still another study of the effects of medication, McMahan and

Greenberg (1977), found that some of the subjects, in both the exper-
imental and control groups, evidenced a reduction in soft-signs. Howev-
er, in both experimental and control groups several of the forty-four
hyperactive children in the study evidenced more soft signs at the con-
clusion of the experiment!
Wherry and Reeves (1987), and McMahan and Greenberg (1977),
have highlighted the problems when trying to ascertain if medical inter-
ventions will reduce the presence of soft-signs, including indices of mo-
tor incoordination. The vexations they wrote about also included the
lack of reliable measures of soft-signs, and the sometimes paradoxical
effects of medications when applied to hyperactive children.
Further conundrums are seen in the data from a study by Ross (1982).
They found that the medication they employed resulted in the childrens'
teachers reporting them more manageable and educable. However, sig-
nificant changes in academic scores were not forthcoming. This kind of
finding has also surfaced when learning disabled children are medicated.
These latter data point to the probability that, while medication usually
improves attention and reduces hyperactivity, medication needs to be
paired with intelligently applied remedial strategies and within well con-
ceived program, in order for significant improvements in both academic
and motor abilities to occur. Ross (1982) also expresses concerns about
the use of medication in an extensive review of the topic. Both clinical
observations and experimental data thus support the judicious use of
medication in programs for hyperactive, poorly coordinated children,
but only if paired with intellectually applied remediation.
Wherry and his colleagues also noted, in a medication change study,
that improved response time in learning tasks occurred in children who
were given chemical help to control their hyperactivity (Wherry et al.
1 969). It is hoped that research in the future will further explore the effi-
cacy of potentially useful medical accompaniments to traditional forms
of motor therapy.
In summary, the somewhat limited evidence available suggests that,
under optimum circumstances, some motor skills of young children are
modifiable within limits. The more changes seem to occur in younger
rather than in older populations, and in certain types of motor tasks in
contrast to others. There are apparently optimum ages at which to apply
a structured-instructional program in various motor skills. Between the
ages of about four years and six or seven years seems best.
Changes recorded in investigations in which in ball throwing for dis-
 Coordination Problems Among Learning Disabled Children 1 79

tance and accuracy has been assessed, indicate that these qualities in
normal, and among awkward young children, may be moderately im-
provable through training. In contrast, locomotor activities (hopping,
skipping and the like) appear to be more resistant to change through
education in groups of young children. Available information also indi-
cates that drawing and printing tasks also seem modifiable through the
application of effective educational strategies that include specific mo-
tor practice of the tasks involved (Cratty & De Oliveira 1989) (Cratty et
al. 1972) (Chapter 7).
In the few available studies of awkward children, the data indicates
that coordination tasks, and related activities seem modifiable with train-
ing. Moreover, remedial efforts may be assisted with the judicious ap-
plication of medication when hyperactivity accompanies motor
incoordination. However, the presence of soft signs reflecting poor coor-
dination may persist through childhood and into the teens. With effec-
tive interventions, the changes that are recorded may occur in specific
and useful "splinter skills." However, the underlying neurological deficits
seem to remain. Finally, interventions throughout an awkward young-
ster's life need to be accompanied by supportive behaviors emanating
from family members, in order to reduce or eliminate undesirable social-
emotional side-effects (Losse 1991).
Also, the available data indicates that retrogression in fitness and
physical coordination may take place if effective remediation is not insti-
tuted (Cratty et al 1 972) (Cratty & Datrahim 1992). The best progress ap-
pears to take place when programs are carefully designed, and individual
differences are provided for (Rarick & Broadhead 1968).
As is true of other remedial programs, including physical therapy,
speech-language enrichment and occupational therapy, the outcomes of
attempts at improving the motor coordination of an individual child are
often difficult to predict. Moreover, the nature of the possible neural ad-
justments, underlying modifications of physical skills, are also not well
known at this time.

SUMMARY AND OVERVIEW

The data reviewed indicates that many learning disabled youngsters dis-
play motor coordination qualities inferior to current developmental aver-
ages. These investigations have also produced several findings useful to
consider when planning school programs for this type of population. For
example, it appears that learning disabled girls may present special prob-
180 Bryant J. Cratty

lems when confronted with physical activity and physical education. They
may lack both motor activity capacities, and also harbor extremely nega-
tive feelings about how they both look and function in motor skill situa-
tions.
The marked delays in fitness recorded in the studies surveyed could be
explained in several ways. One viable supposition is that poorly coordi-
nated learning disabled youngsters tend to avoid physical activity in gen-
eral and thus evidence the results of this avoidance in scores reflecting
poor fitness levels (reflecting what has been termed a 'disuse' syn-
drome). When working with groups of learning disabled children, close
attention should be paid to motivational factors and to employing strate-
gies designed to enhance their self-esteem. Most of the data we and oth-
er have obtained strongly suggest that many learning disabled
youngsters are not happy with their body's appearance and with the
sports skills they are able to exhibit.
Current evidence also indicates that important sub-groups are present
both within populations of awkward children and also groups of the
learning disabled (Lubs et al. 1991). On the basis of this data, it appears
that learning disabled children may be divided into at least four sub-
groups, relative to physical competencies. These include one group who
is relatively free of motor problems, and indeed may be able to compen-
sate for academic deficiencies through vigorous and sustained participa-
tion in recreational sports, and in related activities. A second sub-group
apparently consists of individuals who evidence motor planning prob-
lems along with academic difficulties.
There is recent evidence that this sub-type may be pervasive within
family complexes (Regehr & Kaplan 1988). A third group may evidence
adequate skills and fitness, but require a longer period of time to acquire
complex skills because of the presence of dyspraxias of various kinds.
Still another sub-group of the learning disabled may be able to learn
skills reasonably well, but lack the muscular and cardiovascular fitness
and the coordination needed to fully and vigorously participate in sports
and games. This fourth group seems to possess physical capacities that
remain underdeveloped, because they apparently lack the motivation to
participate in vigorous physical activities.
Data from several studies indicate that motor planning problems in the
learning disabled are pervasive. For example, Rie refers to the problems
learning disabled children have executing complex serial skills (1987).
Important to consider in these data, in addition, is the lack of age-trends
in the scores obtained. This finding suggests that basic problems in se-
 Coordination Problems Among Learning Disabled Children 181

quencing may persist in learning disabled populations. If this is true, old-

er learning disabled children and adolescents should also be patiently
taught new and complex skills, as is true when dealing with younger chil-
dren within this type of population.
Further longitudinal studies of motor planning abilities and disabilities
among this population are currently underway. Data from longitudinal
studies available substantiate the persistence of motor problems, and
neuro-motor soft signs, among groups of clumsy children for as long as
ten years.
Overall, this and similar data suggest that motor coordination prob-
lems are an additional difficulty with which many learning disabled chil-
dren must contend. Thus helping the learning disabled to improve
physically should be an important goal to be pursued along with strate-
gies intended to elicit academic competencies. Not attending to the
coordination, fitness, and sport participation needs of learning disabled
children, displaying deficiencies in these task areas, is likely to blunt the
self-esteem of youngsters who do not need additional evidence of their
incompetencies. The elevation of motor-skill and fitness capacities may
have some 'overflow' effect into academic work. However, further re-
search is needed to determine the manner in which the intervening vari-
able, self-esteem, is likely to be positively influenced by the acquisition of
increased physical competencies, and then in turn to find out if elevation
of the self-concept will positively influence classroom effort and perfor-
mance.

BIBLIOGRAPHY
Abbir M. Douglas, H., & Ross, K. (1978). The clumsy child syndrome: observation in case stud-
ies referred to the gymnasium of the Adelaide Children's Hospital. Medical Journal of
Australia, 1, 65-69.
Arnheim, Daniel D., & Sinclair, W. A. (1975). The Clumsy Child:A program of motor therapy, C.
V. Mosby, St. Louis.
Ayres, A. J. (1972). Types of sensory integration dysfunction among disabled learners, Amen.
can Journal of Occupational Therapy, 26, 13—18.
Barbeau, A. (1982). "History of movement disorders and their treatment" in Barbeau A, (Edi-
tor). Disorders of Movement, Lippencott, Philadelphia, PA. p. 1—29.
Benton, A. L. (1959). Left.right discrimination and finger localization, development and pathol-
ogy, Heober.Harper Books, New York.
Bremmer, M. N., & Gillman, S. (1966). Visuomotor ability in children—a survey, Developmen-
tal Medicine and Child Neurology, 8, 686-703.
Bruininks, R. H. (1978). Bruinink's Oseretsky Test of Motor Proficiency, American Guidance
Service, Circle Pines, Minnesota.
182 Bryant I. Cratty

Brying G. & Michelsson, K. (1984). Neurological and Neuropsychological deficiencies in dys-

lexic children with and without attentional disorders. Developmental Medicine and
Child Neurology 26, 765-773.
Clements, S. D. (1966). Minimal brain dysfunction in children. (USPHS Publication #141, US
Government Printing Office. Washington D.C.
Cratty, B. J. (1975). Remedial Motor Activity for Children, Lea and Febiger, Philadelphia, PA.
Cratty, B. J. (1989). Perceptual and Motor Development of Infants and Children, 3rd Edition,
Prentice-Hall mc, Englewood Cliffs, New jersey.
Cratty, B. j. (1995). Clumsy Child Syndromes, Description, Evaluation and Educational Implica-
tions. Harwood Academic Press, Philadelphia Penna.
Cratty, B. J., & DeOliveira, I. J. (1989). Printing Behavior in Children: Seven Case Studies, un-
published Monograph, Department of Kinesiology, university of California, Los Ange-
les.
Cratty, B. J., Delrahim, M. (1991). The Self-concept of children with coordination problems,
Accepted Brazilian journal of Movement Studies.
Cratty, B.j., Miyahara, M., & DeOliveira, I.j. (1991). Wahrnehmungs-und motorische Fahig-
keiten von Iernbehindereten Kindern Und jugendlichen (Perceptual and Motor Abilities
of Learning Disabled Children and Youth). Motorik, 14, 173—184 (in German).
Cratty, B. J., Ikeda, N., Martin, M. M., jennett, C., & Morris, M. (1972a). Changes in selected
perceptual-motor attributes of children with moderate coordination problems. In
Cratty, B. j., lkeda, N., Martin, M. M., jennett, C., & Morris, M., MovementActivities, Mo-
tor Ability and the Education of Children, Charles C. Thomas, Springfield, Illinois.
Critchley, M. & Critchley, E. A. (1 978). Dyslexia defined. Charles C. Thomas. Springfield Illinois.
Cummins, R. A. (1991). Sensory-Integration and learning disabilities: Ayres' factor analyses
reappraised. Journal of Learning Disabilities, 24, 160-168.
Delrahim, M., Crafty, B. I., Goldman, R. (1991). The effects of training on the power.strength
development of learning disabled youngsters. Accepted, Brazilian Journal of Movement
Studies.
Denckla, M. B. (1973). Development of speed in repetitive and successive finger-movements
in normal children. Developmental Medicine and Child Neurolog) 15, 635-645.
Deren, 5. (1986). Children of Substance Abuse: A Review of the Literature, Journal of Sub-
stance Abuse Treatment 3, 77-94.
Gerstmann (1927). Fingeragnosie und isolierte agraphie; em neues syndrom, Ztschr. Neuro!.
PsychiaL, 108, 152-177.
Getman, G. N. (1952). How to develop your child's intelligence, A research publication,
Luverne, Minnesota, G. N. Getman.
Gottlieb, M. I. (1987). Chapter 31, Attention Deficits Disorders, Hyperkinesis, and Learning
Disabilities, Controversial Therapies in Gordon N & McKinlay I. (Eds). Neuro!ogically
Handicapped Children: Treatment and Management, Blackwell Scientific Publications
Boston pp 251—261.
Gschwend, V. G. (1988). Neuropsysiologisch Grundlagen der Bewegungstherapien.
(Neurophysiological bases of movement therapy). Der Kinderazt, 19, 1589—1597.
Gubbay S. S. (1975). The clumsy child: A study of developmental apraxic, and agnosic ataxia,
W. B. Sanders, Co, Philadelphia.
Hall, D. M. B. (1988). Clumsy Children, British Medical Journal, 296, 375—376.
Henderson, S. E. & Hall, D. (1982). Concomitants of clumsiness in young schoolchildren, De-
velopmental Medicine and Child Neurology, 24, 448-460.
Henderson, S. E., & Stott, D. H. (1977). Finding the clumsy child: Genesis of a test of motor
impairment. Journal of Human Movement Studies, 3, 38—48.
 Coordination Problems Among Learning Disabled Children 183

Hertiz, M. E., & Shapiro, T. (1987). Chapter 4. The assessment of Nonfocal Neurological Signs
in School-Aged Children, in Tupper, E. E. (Edtor), Soft Neurological Signs. pp 71-94.
Grune and Stratton, New York.
Hoare, D. & Larkin, D. (1991). Coordination Problems in Children, No 18 State of the Art Re-
view, National Sports Centre, Australian Sports Commission, Canberra, Australia.
Hoare, 0. & Larkin, D. (1991). Kinesthetic abilities of clumsy children, Developmental Medi-
cine and Child Neurology, 33(8). 871-678.
Hulme, C., Biggerstaff, A., Morgan, G., & McKinlay, I. (1984). Visual, kinesthetic and cross-mo-
dal judgements of length by clumsy children: A comparison with young normal children.
Child care; health and development, 10, 117-124.
Iloeje, S. 0., (1987). Developmental Apraxia among Nigerian children in Enugu, Nigeria, De-
velopmental Medicine and Child Neurology, 29, 502-507.
Jaklewicz, H. (1980). Follow-up studies on dyslexia and dysorthographia. Psychiatria Polska,
14, 613-619.
Kavale, K. & Mattson, P. (1983). One jumped off the balance beam: Metanalysis of perceptual-
motor training. Journal of Learning Disabilities, 16, 166—173.
Kephart, N. C. (1956). The slow learner in the classroom, Charles E. Merrill, Columbus Ohio.
Kimura, D. (1976). The neural basis of gesture qua language, In ft, Whitaker & H. A. Whitaker
(eds). Studies in Neuolinguistics, Vi, Academic Press, New York.
Kinnealey, M. (1989). Tactile functions in learning disabled and normal children. Reliability
and validity considerations. Occupational Therapy Journal of Research, 9, 3-15.
Klasen, E. (1972). The syndrome of specific dyslexia. University Park Press, Maryland.
Knuckey, N. W., Apsimon, T. T., & Gubbay, 5. 5. (1983). Computerized axial tomography in
clumsy children with developmental apraxia, and agnosia, Brain & Development, 5,
14-19.
Laszlo, J. I., Bairstow, P_i. (1980). The measurement of Kinesthetic sensitivity in children and
adults, Developmental Medicine and Child Neurology, 22, 454-464.
Laszlo, . I., Bairstow, P.1. (1983). Kinesthesis: Its measurement, training, and relationships to
motor control Quarterly Journal of Experimental Psychology, 35, 411—421.
Laszlo, . I., Bairstow, p. j. (1 985a). Perceptual-motor behaviour: Developmental Assessment
and Therapy. Holt, Rinhart and Winston, London.
Laszlo, J. I., Bairstow, P.1. (1 985b). Kinesthesis sensitivity test. Rinehart and Winston. London.
Laszlo, . I., Bairstow, P. J., Bartrip, J. & Rolfe, U. T. (1988). Clumsiness or perceptuo-motor dys-
function? in Cognition and Action in Skilled Behaviour. A. M. Colley & i. R., Beech, (edi-
tors). Elsevier Publishers, By, North Holland.
Laszlo, J. I., & Bairstow, P. J. (1986). Perceptual-Motor Behaviour Holt, Rinehart & Winston,
New York.
Lerer, R. J. (1981). An open letter to an occupational therapist Journal of Learning Disabilities.
22—23.
Lerer, R. J., & Lerer, M. p. (1976). The effects of methyiphenidate on the soft neurological signs
of hyperactive children. Pediatrics, 57, 521 —525.
Lesny, I. A. (1980). Developmental dysgraphia-dysgnosia as a cause of congenital children's
clumsiness, Brain and Development, 2,69-71.
Lord, R., & HuIm, C. (1987). Kinesthetic sensitivity of normal and clumsy children, Develop-
mental Medicine and Child Neurology, 29, 720—723.
Losse, A. Henderson, S. E., Elliman, D., Hall, D., Knight, E., & iongman, M. (1991). Clumsiness
in children-Do they grow Out of it? A 10-year follow-up study, Developmental Medicine
and Child Neurology, 33, 55-68.
 184 Bryant J. Cratty

Lubs, H. A., Duara, R., Levin, B., Jallad, R., Lubs, M. L. Rabin, M., Kushch, A., & Gross-Glenn, K.
(1991). Chapter 4 "Dyslexia sub-types: Genetics Behavior and Brain Imaging." in D. D.
Duane, & D. B., Gray eds. The Reading Brain: The Biological Basis of Dyslexia, New York
Press, Parkton Maryland, pp. 89—118.
Luria, A. R. (1966). Higher Cortical Functions in Man, Basic Books, Consultants Bureau, New
York.
McMahan, S. A. & Greenberg, 1. M. (1977). Serial Neurologic examination of hyperactive chil-
dren, Pediatrics, 59, 384-587.
Miyahara, M. (1992). Sub-types of learning disabled children and youth, based upon meas-
ures of gross motor functioning. Unpublished study, Department of Kinesiology, UCLA.
Miyahara, M., Cratty, B. J., & Goldman, R. M. (1990). Praxic behaviors among learning dis-
abled Children and youth, Submitted to journal of Movement Behavior.
Myers, P. I. & Hammill, D. D. (1990). Learning Disabilities: Basic Concepts, Assessment Prac-
tices, and Instructional Strategies. Pro-Ed, Austin Texas. p. 439—441.
Mykiebust, H. R. (1973). Developmental disorders of written language: studies of normal and
exceptional children, Grune and Stratton, New York.
Nichols, P. L. (1987). Minimal Brain Dysfunction and Soft Signs: The Collaborative Perinatal
Study. in Tupper, D. E. (editor). Soft Neurological Signs pp. 179-200. Grune & Stratton,
New York.
Obersteiner, H. (1881). On allochiria; a peculiar sensory disorder, Brain, 4, 153—163.
O'Hare, A. E. Brown, J. K. (1989). Childhood dysgraphia: Part 1 An illustrated clinical classifica-
tion, Child: Care, Health and Development, 15, 79-102.
Oseretsky, N. A. (1931). Methoden der untersuchung der motorile, Heft 57. Beihefte Zur
Zeitschrift Fur Angewandte Psychologie, Barth, Leipzig.
Paine, R. S. (1968). Syndromes of 'minimal cerebral damage,' Pediatric Clinics of North Amer-
ica, 15, 779—801.
Piers, E. V. & Harris, D. B. (1964). Age and other correlates of self-concept in children, Journal
of Educational Psychology, 55, 91-95.
Rarick, G. L., & Broadhead, G. L. (1968). The effects of individualized versus group oriented
physical education programs on selected parameters of the development of educable
mentally retarded, and the minimally brain injured children. Unpublished Monograph,
University of Wisconsin, Madison, Wisconsin.
Reeves, J. C. & Wherry, J. S. (1987). Chapter 10, Soft Signs in Hyperactivity, in Tupper, D.E.
(Ed). Soft Neurological Signs, Grune & Stratton, New York.
Regehr, S. M. & Kaplan, B. J. (1988). Reading disability with motor problems may be an inher-
ited sub-type. Pediatrics, 82, 204—210.
Rie, E. D. (1987). Chapter 9 Soft Signs in Learning Disabilities, in Tupper, D. E. (Ed). Soft Neuro-
logical Signs, Grune & Stratton, New York. (pp 201—224).
Rie, E. D., Rie, H. E., Steward, S., & Rettemnier, 5. (1978). An analysis of neurological soft signs
in children with learning problems. Brain and Language, 6, 32-46.
Ross, D. M. & Ross, S. A. (1982). Hyperactivity: Current Issues, Research and Theory, New York,
John Wiley and Sons.
Rutter, M. Graham, P. & Yule, W. (1970). A neuropsychiatric Study in childhood. Clinics in De-
velopmental Medicine Nos 35—36, Lippencott, Philadelphia.
Seaman, J. A. & Depauw, K. P. (1982). The New Adapted Physical Education, A Developmen-
tal Approach. Mayfield Publishing Co. Palo Alto, California.
Short, H., & Crawford, J. (1984). Last to be chosen the awkward child, Pivot, 2, 32-36.
 Coordination Problems Among Learning Disabled Children 185

Skekim, W. 0., Dekirmenjian, H., & Chapel,J. L. (1979). Urinary MHPG excretion in minimal
brain dysfunction and its modification by d-amphetamine. American journal of Psychia-
try, 136, 667-671.
Smythe, T. R., & Glencross, D. J. (1986). Information processing deficits in clumsy children.
Australian Journal of Psychology, 38, 13-22.
Stott, D. H., & Marston, N. C., & Neil!, S. J. (1971). The Bristol Social Adjustment Guides, 4th
Edition, Educational Testing Services, San Diego.
Stott, D. H., Moyes, F. A., & Henderson, S. E. (1984). Test of Motor Impairment, Henderson
revision, The Psychological Corporation San Antonio, Texas.
Strauss, A. A. & Lehtinen, C. E. (1947). The Ps ychopat hologyand Education of the Brain-injured
Child, Gruen and Stratton, New York.
Sugden, D. & Wann, C. (1987). The assessment of motor impairment in children with moder-
ate learning disabilities. British Journal of Educational Psychology, 57, 225—236.
Touwen, . C. L., and Prechtl, H. F. R. (1970). The Neurological examination of the child with
minor nervous system dysfunction, London, Clinics in Developmental Medicine,
Heinemann.
Tupper, D. E. (1987). Soft Neurological Signs. Grune & Stratton, New York.
Van Rossum, J. H. A., & Vermeer, A. (1990). Perceived competence: A validation study in the
field of motoric remedial teaching. International journal of Disability, Development and
Maturation, 37, 71-81.
Wolff, P. H. & Cohen, C., & Drake, C. (1984). Impaired motor timing control in specific reading
retardation, Neuropsychology, 22, 587-600.
Wolff, P. H., & Michael, G. F., & Drake, C. (1990). Rate and Timing precision of motor coordina-
tion in developmental dyslexia, Developmental Psychology, 26, 349—359.
LECTURE 8

Dennis P Cantwell, M.D.

University of California, Los Angeles
Joseph Campbell Professor of Child Psychiatry
Director of Residency in Child Psychiatry

PHARMACO LOG I CAL

INTERVENTIONS FOR
CHILDREN WITH
LEARNING AND
PSYCHIATRIC DISORDERS

'Even though I may become frustrated again, / know that

I can succeed and will succeed, with maybe a little more
work than others."
188 Dennis P. Cantwell and brian Baker

Introduction by Richard L. Goldman

I'd like to welcome everyone and I am gratified by tonight's attendance.
Tonight's topic is extremely relevant, controversial, and misunderstood. To
educate us, we are extremely fortunate to have as our speaker, Dennis P.
Cantwell, M.D. who is the Joseph Campbell Professor of Child Psychiatry
at University of California Los Angeles (UCLA) Neuropsychiatric Institute.
Dr. Cantwell was a member of the American Association on Mental Defi-
ciency Task Force on Classification of Mental Retardation as well as on the
task forces to develop DSM.lll, DSM-lll-R and DSM-IV. He is the author of
numerous journal articles, book chapters and books such as Fundamen-
tals of Child and Adolescent Psychopathology. His accomplishments as a
clinician, teacher, reseracher, and administrator have been recognized by
his receipt of several prestigious awards, honors and prizes, including the
American Psychiatric Association Award for Research in Psychiatry.
To speak about Psychopharmacological Interventions for Children
with Learning and Psychiatric Disorders, it is my great pleasure to
introduce Dr. Dennis Cantwell.

Dr. Dennis P. Cantwell

This chapter provides an overview of the current thinking about the use of
medication treatment for common childhood psychiatric problems. Most
of the children seen by us at the UCLA Neuropsychiatric Institute have
multiple problems in the areas of learning, cognitive functioning, social
skills, interpersonal relationships, and mood alterations. In addition to me-
dications, these youngsters usually require a variety of other interventions
such as educational assistance, family counseling, and individual psycho.
therapeutic help. Generally, the medication is given to ameliorate a cer-
tain specific set of symptoms; whereas the other interventions are given to
ameliorate a different set of specific problems.

A significant amount of time elapsed between the drafting of this chapter and its
publication. During this time new data have appeared in many of the areas
discussed in the chapter. Readers interested in an update are referred to:
1. Textbook of Pharmacotherapy for Child and Adolescent Psychiatric Disorders.
D. Rosenberg, J. Holttum, S. Gershon. Brunner/Mazel, New York, 1994.
2. Child and Adolescent Clinical Psychopharmacology, Second Editions. W.H.
Green, Williams and Wilkins, 1996.
 Pharmacological Interventions 189

Our knowledge base about the use of psychotropic medications in

children and adolescents has expanded enormously in the last two de-
cades. Nonetheless, compared to our knowledge about psychotropic
medications for adults, what is known about children still lags far behind.
In fact, this is one area that the Federal Government (National Institute of
Mental Health) has targeted as a priority for additional research.
There are several reasons why the use of medication is especially com-
plicated with children, and why less is known about medications for chil-
dren. First, as noted above, most children have a complex of problems,
symptoms, or diagnoses rather than a single problem, symptom, or diag-
nosis. Multiple diagnoses within one child pose difficulties both for treat-
ment and for evaluating the effects of medication.
In addition to the problem of multiple diagnoses, another problem in
evaluating medication effects is symptom differences. Children with the
same diagnosis do not necessarily have the same symptoms, although
they do have the same types of symptoms or "symptom clusters." Exam-
ples of symptom clusters include: "anxiety symptoms," "depressive symp-
toms," "inattention symptoms," "impulse control symptoms," and
"hyperactivity symptoms." The hyperactivity symptom cluster consists of
symptoms such as: fidgeting, squirming, having difficulty remaining
seated, excessive running around or climbing on things, moving about
excessively during sleep, and always being "on the go." But, all "hyperac-
tive" children do not necessarily exhibit all of the symptoms in the symp-
tom cluster.
A third problem with regard to medication treatment of children is that
symptoms and symptom clusters do not necessarily mean the same
thing across children. Consider, for example, two boys who both mani-
fest "hyperactivity symptoms." One boy manifests "hyperactivity symp-
toms" much of the time, and has the diagnosis of "attention deficit
disorder with hyperactivity." The second boy has the diagnosis of an
"anxiety disorder," and manifests the hyperactivity symptoms only dur-
ing periods of high anxiety. If given stimulant medication, the first boy
should experience a decrease in his activity level. Conversely, if given
stimulants, the second boy would likely become more active.
This example illustrates that the same symptoms in different children
may reflect different underlying diagnoses. When they do, the children
will respond differently to the same medication. As well as showing that
there are diagnosis-specific effects of medication, this example also high-
lights the critical importance of a very careful evaluation and a different
diagnosis before any medication is started.
190 Dennis P. Cantwell and Lorian Baker

Medication is typically prescribed based on the fact that a child has a

particular diagnosis and that, within that diagnosis, a medication is
known to produce certain positive symptomatic effects. However, one
difficulty with this approach is that medication has two very different
types of effects. One is the direct effect of producing certain physiologi-
cal phenomena that result in the modification of certain symptoms. The
other is an indirect or psychosocial effect which, in the long run, can be
as important as the direct effect.
For example, consider an 11 year old boy who still wets the bed. For
this boy, an anti-neuritic medication (e.g., Tofranil or Imipramine), will
have the direct effect of blocking urination, probably through a local ef-
fect on the bladder. However, the drug will also have the indirect effect
of allowing the boy to go on sleep-overs or to attend overnight camp
without any fear of embarrassment due to bed wetting. To the young pa-
tient, this indirect effect is probably more important than the direct ef-
fect.
Below, we will outline some of the major childhood and adolescent
psychiatric disorders and discuss the pharmacological interventions that
are appropriate for them.

ATTENTION DEFICIT (HYPERACTIVITY) DISORDER

The most common childhood psychiatric disorder is "attention deficit (hy-

peractivity) disorder" (ADD). This disorder is characterized by three symp-
tom clusters: hyperactivity symptoms, impulsivity symptoms, and
attentional symptoms.
The most important symptom cluster in this disorder is the attentional
symptom cluster. Children with ADD have attentional problems such as
difficulty zeroing in on the right stimulus (for example, the teacher's
voice rather than a neighbor's voice) and difficulty keeping their atten-
tion focused on particular stimulus. They are highly distractible, and, con-
sequently, tend to have serious problems in school.
Although these children have an attention deficit, it is not true that
they are incapable of attending to anything. In fact, they can attend quite
well to certain types of stimuli, for example, Nintendo and action televi-
sion (i.e., Teenage Mutant Ninja Turtles or World Wrestling Federation
matches). They can also learn some things quite easily (e.g., sports statis-
tics), but they usually have difficulty learning reading, mathematics and
other types of higher-level cognitive activities.
 Pharmacological Interventions 191

In addition to attentional problems, children with ADD usually have

problems with impulse control in both the cognitive and behavioral
areas. Two example of behavioral impulsivity are blurting out the an-
swers to questions before the teacher has finished asking the questions,
and butting into other children's games without first asking to be allowed
to join in. An example of cognitive impulsivity would be doing a whole
set of problems incorrectly based on a quick first impression (e.g., doing
addition on a series of multiplication problems, based upon the impres-
sion that the "x" is a plus sign).
It is currently thought that there are three subtypes of ADD: "attention
deficit disorder with hyperactivity" (ADDH), "attention deficit disorder
without hyperactivity" (ADDW). This means that not all children who
have ADD have the cluster of hyperactivity symptoms (which, as noted
above consists of symptoms such as fidgeting, squirming, having difficul-
ty remaining seated, excessive running around or climbing on things,
moving about excessively during sleep, and always being "on the go").
Recent data suggests that children with ADDH are different from chil-
dren with ADDW in other ways as well as with regard to the hyperactiv-
ity symptom cluster (Cantwell & Baker, 1992).
It was once estimated that between 3 and 5% of school-aged children
had ADD. However, it now appears that the disorder is much more com-
mon. In a currently ongoing study being conducted at Yale University
(Shaywitz et al., 1988), one out of every five youngsters in kindergarten
through third grade classes were found to have ADD symptoms.
This study is also finding that, while ADD is more common in boys
than in girls, there are many more girls with this problem than was once
thought. For some reason, the girls are not referred for professional
evaluation as often as boys, even though they are still there in the corn-
mu nity.
The lower referral rate for girls may be because girls have fewer
associated problems such as oppositional, negativistic, or aggressive be-
haviors. These kinds of behaviors, which are common in boys with ADD,
are highly disruptive and therefore likely to result in referral for profes-
sional help. Girls who have ADD tend not to have these behaviors, and,
instead, tend to be quitely inattentive and to have learning problems.
The Yale study also is finding (Shaywitz et al., 1990) that learning dis-
abilities are equally common in girls as in boys, at least in young (kinder-
garten through third grade) children. However, learning disabled boys
are more likely than learning disabled girls to be referred for professional
192 Dennis P. Cantwell and brian Baker

evaluation. Again, this appears to be the result of associated problems

(such as disruptive classroom behaviors) in the boys.
ADD is particularly likely to be present in children who have learning
problems, speech/language disorders, and other forms of psychiatric
problems (Baker & Cantwell, 1992; Huessy, 1992). The psychiatric prob-
lems that most often occur along with ADD are: conduct disorder (juve-
nile delinquency), oppositional disorder, and depression. In fact, the
majority of children who have ADD also have other programs or diag-
noses in addition to the ADD. Naturally, the presence of such other
"comorbid" disorders affects the particular kind of intervention that is
most appropriate for a child.
ADD is a condition that is probably present at conception. We often
hear mothers of ADD children say things like "Johnny was hyperactive in
the womb" or "The day Johnny was born, Iput on my Reeboks and! have
been running ever since." Parents are often able to identify problems in
the areas of attention, poor impulse control, and an excess of motor ac-
tivity, during the toddler years. The younger a child is, however, the more
difficult it is to make an accurate diagnosis. This is because short atten-
tion span and poor impulse control are typical in young children.
As babies, children with ADD may have been colicky. They often have
what Stella Chess (1979) has called a "a difficult temperament," that is,
they don't sleep very well, they don't maintain a day/night pattern very
well, and they are very difficult to soothe. Children with ADD have high
rates of allergies (around 25%), which may make the ADD behaviors
worse, partially because allergy medications (e.g., steroids, inhalers and
antihistamines) may cause more hyperactivity.
ADD symptoms are very persistent over time, and, contrary to what
was once believed, ADD children do not outgrow the disorder at puber-
ty. Often, in fact, ADD symptoms may become worse in adolescence.
Although impulsivity and attention generally improve as the child gets
older, the majority (approximately 80%) of ADD patients do not ever be-
come completely normal in these areas. As a result, adolescents with
ADD typically do not well in school, and, later, when they enter the job
market, entry tends to be at a lower level than for their peers.
The most common outcomes of ADD, if not treated, is the develop-
ment of additional problems, most often learning disabilities, antisocial
behaviors, and substance abuse (usually alcohol abuse). One follow-up
study (Satterfield et al., 1 982), found that 25% of ADD teens had been
incarcerated by the age of 18, and 55% had been arrested for commit-
ting a felony.
 Pharmacological Interventions 193

The question of whether ADD persists into adult life has only recently
been examined. It appears that between 40% and 66% of cases of child-
hood ADD do persist into adult life.
The term "ADD, residual state" (ADD-RS) is used to describe adoles-
cents and adults who had ADDH when they were younger. These indi-
viduals have attentional symptoms, but different attentional symptoms
from those seen in ADD youngsters. The adults have an "internal fidgeti-
ness" and can't relax. They overreact to environmental stimuli, tend to
have trouble sitting still, and have histories of multiple job changes.

INTERVENTIONS FOR ADD

As stated above, treatment for ADD involves a "package" of interventions.

Intervention must begin with a complete evaluation, including assessment
of behaviors at home and at school, assessment of academic achievement
performance, and assessment of related areas of development (e.g.,
speech, language, motor coordination). Once a child's deficit areas are
identified, an appropriate treatment package can be created using the
relevant intervention strategies such as educational assistance, medica-
tions, linguistic/cognitive interventions, parent management training, be-
havioral training, and social skills training.
School placement is probably the most important intervention consid-
eration, because it affects the child five days a week, six hours a day. Al-
though most ADD children go to regular schools, special considerations
(such as small class size) need to be made. Because school placement is
very crucial, it should be re-evaluated at the end of every school year to
ascertain that there is always the best possible "fit" between the child
and his classroom. Other kinds of educational intervention (such as one-
to-one special tutoring) may also be needed.
Our research (Baker & Cantwell, 1 992) indicates that as many as 50%
of ADD children also have speech or language disorders. For these chil-
dren, speech/language therapy is useful. Parent management training
can be very helpful because with ADD children especially good parent-
ing skills are needs.
For some ADD children, cognitive behavioral therapy can prove bene-
ficial in those behavioral areas where medications might not be effective.
Cognitive behavioral therapy trains the child to think differently, or to use
different cognitive strategies (Braswell & Bloomquist, 1991).
Social skills training is useful for those ADD children who have a lack
of social "savoir faire" and do not recognize the important nuances of
194 Dennis P. Cantwell and Lorian Baker

social interaction. Social skills can be taught individually, in a small group

setting or in a larger special classroom (Swanson et al., 1990).

MEDICATION INTERVENTIONS FOR ADD

In order to understand how psychiatric medications work, some under-

standing of neurophysiology and brain functioning is needed. Basically,
electrical impulses are transmitted from the brain down the nerve cell.
There are gaps between one nerve cell and the next one (called "syn-
apses") and certain chemicals in the brain (called "neurotransmitters") act
as messengers from one brain cell to another across the synapses. There
are a variety of these neurotransmitters, for example, Serotonin, Norepi-
nephrine, and Dopamine. The psychotropic medications that alter ADD
symptoms do so by acting on these various neurotransmitters.
All ADD children do not respond to medication. However, the evi-
dence is overwhelming that medication with any other kind of therapeu-
tic intervention is better than medication without any other interventions
or than other interventions alone. Therefore, it is a disservice to the aver-
age child with ADD not to try medication.
Generally, medication is very effective for managing many of the
symptoms of most ADD children. Different medications (discussed be-
low) have different strengths and weaknesses. However, there are some
issues that must be considered with all forms of medication.
One issue is that many children are negative about taking medication.
This is especially true at adolescence, which is a time of body-image
formation when there is a strong emotional need not to be "different."
Taking a drug may confirm to youngsters that they are different, and con-
sequently, many are non-compliant about taking medications. In fact,
approximately 50% of adolescents are non-compliant about taking psy-
chotropic medications.
We have found that it is sometimes helpful to explain the medication
as a "handicap deterrent." A youngster can be told that, just as some
people have to wear reading glasses in order to correct a visual deficit, so
some people need medications in order to improve an attention or con-
centration deficit. The youngster can also be told that taking the medica-
tion is a short-term situation, like wearing a splint or a cast for a sprained
arm or broken leg. However, most ADD children will require medication
throughout adolescence (Clampit & Pirkle, 1983). As the child moves
through adolescence into adult life, the dosage (on a milligram per kilo-
gram of body weight basis) can often be decreased.
 Pharmacological Interventions 195

Another issue with psychotropic medications is that they need to be

monitored carefully. If a child is on medication with a stable dose for a
long time, monitoring can be done every six months or so by telephone.
However, if the medication is being titrated, it needs to be monitored
very closely (e.g., at least on a weekly basis).
Children themselves are notoriously bad at reporting medication ef-
fects. Even adolescents who have higher levels of cognitive functioning,
and who are more reflective about themselves, generally cannot begin
to describe what medication is doing. In fact, many of them deny that the
has any effect, and may simply attribute medication effects to their own
"trying harder' to concentrate.
Rating scales or parent and teacher reports are the best ways of moni-
toring drug effectiveness, since these give quantitative, objective indica-
tions of how the child performs in both the educational and home
environments. Rating data is needed for "baseline" (i.e., before the me-
dication treatment is started) as well as on various doses of medication.
The third issue with medication is that there may be major short-term
changes in behavior when the ADD child is first given the medication.
For example, the child may have an increased sensitivity to environmen-
tal noise (e.g., an air conditioning unit), and he becomes even more ac-
tive for a few days or weeks. Possibly these short-term changes are due to
the neural receptor sites becoming attuned to the medication.
There are two general types of medication that are very effective for
the treatment of ADD: stimulants and tricyclic antidepressants. Other
medications are also sometimes used for the treatment of ADD. These
types of education are discussed separately below.

Stimulants
Stimulants are the most commonly used medication for the treatment of
ADD. Currently, four major types of stimulants are used: methylphenidate
(or Ritalin); amphetamines or (Dexedrine); magnesium pemoline (Or Cyl-
ert); and fenfluramine hydrochloride (or Pondimin), which is only used in-
frequently.
Approximately three-quarters of all ADD children respond positively
to at least one of the stimulants. The positive effects of stimulants in-
clude: decreases in motor activity, improvements in sustained attention,
decreases in impulsivity and distractibility, improved motivation, and im-
provements in accuracy and speed of academic achievement perfor-
mance (Dulcari, 1990; Kavale, 1982).
196 Dennis P. Cantwell and Lorian Baker

Overall, the three major stimulants (i.e., Ritaliri, Dexedrine and Cylert)
have about the same level of effectiveness. However, many children will
respond positively to one stimulant and not to another stimulant. The
reason for these differential responses is that the different stimulants act
upon different neurotransmitter systems. For example, amphetamines ef-
fects primarily norepinephrine, and methylphenidate primarily effects
dopamine. Cylert effects both norepinephrine and dopamine, but less
strongly than the other two drugs. Pondimin lowers bloods serotonin,
and probably brain serotonin as well.
Although we know that individual respond differently to the various
stimulants, we do not know to predict individual responses. Thus, we
cannot predict whether a particular child will respond better to one me-
dication than to another, or whether he will have fewer side effects with
one drug than another. As a result, treatment must use a trial-and-error
approach. First one medication must be tried at a low dosage, and then
the dosage must be gradually titrated up while assessing whether there
are positive clinical effects and/or negative side effects.
It was once thought that stimulants were responsible for growth sup-
pression in children. However, prospective studies have shown that
there are no long-term effects on either height or weight (Beck et al.,
1975; Hechtman et al., 1984). In fact, stimulants have been used to the
last 50 years with ADD children and are considered to be both effective
and safe (Cantwell, 1 980). Common side effects include increased heart
rate, increased gastro-intestinal movements (stomachaches), and head-
aches. Rarely, the medication may cause tics. However, in clinical prac-
tice, it is extremely rare to have to discontinue stimulant treatment
because of side effects. A failure to respond to the medication of a more
common clinical problem.
One of the drawbacks of the stimulants is that they are short-acting.
Even the so-called "long-acting" or "slow-release" forms last only six to
eight hours. This means that, by the end of the day, ADD children who
were given stimulants in the morning will no longer show a positive re-
sponse. And, when these children wake up the next morning, it is as if
they had have never had any medication; there is no build-up of the me-
dication, and there is no carry-over of effects from the days before.
Sometimes clinicians recommend reducing the dosage of stimulants
or taking the child off the medication entirely during the weekends or
summer vacation. This practice, called a "drug holiday," was once very
popular, and was motivated by the belief that youngsters would take less
medication over time and therefore would be less effected by growth
 Pharmacological Interventions 197

suppression. However, research has shown that neither the stimulants

nor the "drug holiday" have significant effects on long-term growth rates.
Consequently, we feel that the only good rationale for a drug holiday is
that a child does not need the medication. Frequently, a child will need
the medication on weekends and holidays. For example, an ADD child
who is involved in weekend sports such as softball, will benefit from me-
dication by its reduction of "off task" behaviors (e.g., watching the birds
or kicking the grass) during games.
Furthermore, restarting the medication after a drug holiday can result
in the child suffering a "break in" period, just as if he were starting the
medication for the first time. Agitation, decreased appetite, and/or feel-
ings of fatigue are short-term symptoms that may occur during this break
in period. Presumably these symptoms are due to the neural receptor
sites reacting to the drug as if it was a new drug.

Tricyclic Antidepressants
Tricycles are affective alternative medication treatment for ADD, although
their primary use in this country is for treating adult depression. Standard
tricycles (including imipramine [or Tofranilj and amitriptyline [or Elavil])
have been in use since 1957, and there are numerous other tricyclics avail-
able as well.
Some tricyclics primarily act upon norepinephrine; others primarily
act upon serotonin; and still others primarily act upon dopamine. Be-
cause of their actions upon these neurotransmitters, the tricyclics can af-
fect ADD symptoms in ways similar to the stimulants. Specifically, they
can increase attention span, improve impulse control, decrease fidgeti-
ness, and decrease restless behaviors. Some tricyclics (e.g., clomipra-
mine) are also effective in reducing obsessive-compulsive behaviors, and
therefore may be the best drug for those ADD children who have obses-
sive-compulsive problems.
Although the tricyclics share some effects in common with stimulants,
they are different from the stimulants in three major ways. First, tricyclics
are long-lasting and last all day. This means that once a certain level of
tricyclic medication is built up in the blood stream, the effects remain
constant. There isn't the "up and down" phenomenon that occurs from
morning to evening with stimulants.
Second, tricyclics do not produce stimulant side effects such as appe-
tite suppression, stomachaches or tics. Consequently, tricyclics may be
preferred medications for those ADD children who have developed eat-
198 Dennis P. Cantwell and brian Baker

ing problems from stimulants, or who have a tic disorder which might be
exacerbated by stimulants.
Third, tricyclics have both anti-depressant and anti-anxiety effects.
Thus, they may be the preferred treatment for an ADD child who has
those other symptoms as well as ADD symptoms.
For the average ADD child, however, stimulants are a better choice
simply because more is known about them. Stimulants are also easier to
monitor because they are short acting. For example, one can determine
the effect of particular dose of stimulants within a few days. In contrast, it
takes at least a week for the tricyclics to build up in the blood stream to
the point where their effect can be measured. Also, because of the time
needed for tricyclics to build up in the blood stream, drug holiday are not
possible with tricyclics. For example, if tricyclics are not administered
during the weekend, their level in the blood drops so that the following
Monday, there will be no positive effect from taking the medication
again.

Other Medications For ADD

Clonidine is another medication that may be useful for ADD. It was first
used at Yale as a treatment for Tourette's Syndrome (TS), a tic disorder
(Cohen et al., 1992; Leckman et al., 1991). For those TS patients who also
had ADD, in improvement in the ADD symptoms was observed with Clo-
nidine.
A very small number of ADD patients who do not have TS have been
treated with Clonidine (Hunt et al., 1984). Most of these patients
showed a positive response to the medication, but the nature of the re-
sponse was somewhat different than that which occurs with stimulants
or with tricyclics. Aso, Clonidine is less effective than stimulants for the
cognitive manifestations of ADD. However, for those ADD children who
are also aggressive-disruptive, or who also have tics, it may be a good
medication choice.
One problem with Clonidine, however, is that it is extremely short-act-
ing, and in many cases has to be given as many as five times a day. There
is a long-lasting patch available, but children like to pull it off.
Bupropion (or Wellbutrin) is a new antidepressant that may be some-
what effective for certain children with ADD. Prozac is another new anti-
depressant that may also be effective for certain individuals with ADD.
Although little is known about its effects upon children, when used with
adult ADD-residual state patient, it often has a dramatic positive effect.
 Pharmacological Interventions 199

MOOD DISORDERS

"Depression" and "demoralization" are two mood problems that are very
common in learning disorder adolescents. "Depression" can occur in vari-
ous forms (e.g., major depression and dysthymia), sometimes alternating
with periods of "elation" or "mania" (bipolar disorder, cyclothymic disor-
der). One striking feature of depression is "anhedonia," or an inability to
get pleasure from the things that ordinarily give pleasure.
Mood disorders are extremely common in the general population,
particularly in females. One woman in four will have a significant epi-
sode of depression in her lifetime, as will about one man in ten. This gen-
der differences does not occur until after puberty. Prior to puberty, the
rates of depressive disorders are exactly the same for boys as for girls.
After puberty, the rate is twice as high in girls as in boys.
Depressive disorder are a different from ADD \in that ADD is a chron-
ic problem that is always there, whereas depression is an episodic prob-
lem that can be resolved. Medications do not cure ADD; they simply
alleviate many of the symptoms. If the medications are discontinued, the
disorder will still be present. For depressive disorders medication can be
withdrawn after treatment, and the condition may no longer be present.
However, relapse may occur with time, necessitating retreatment.
A number of medications are effective for depressive disorders in chil-
dren and adolescents. The tricyclic antidepressants (discussed above)
and the newer non-tricyclic antidepressants (e.g., Prozac and Wellbutrin)
may help. When tricyclics are used for depression, different dosages are
given than when the drug is used to treat ADD.
For manic symptoms, Lithium and Tegretol are two medications that
may be useful. Lithium, as an anti-aggressive in those children who exhib-
it isolated outbursts of physically aggressive behaviors associated with
significant mood swings. However, children who are persistently aggres-
sive, do not show this response to Lithium.
The side effects of Lithium include fine hand tremors, and gastrointes-
tinal problems (i.e., nausea, diarrhea, vomiting). These side effects are
related to the concentration of the drug in the blood stream and indicate
when the dosage is too high.
"Demoralization" (or bad feelings resulting from failure in a important
area of life) is a common mood problem, especially in children with
learning problems. "Demoralization" is not "depression;" it is not charac-
terized by anhedonia," and it does not respond to antidepressant (or oth-
er) medications.
200 Dennis P. Cantwell and Lorian Baker

The treatment for demoralization is double-pronged. First, the underly-

ing problem that caused the demoralization must be remedied. For ex-
ample, if the child is demoralized by a severe learning problem and
academic failures, then he needs to be helped to succeed academically.
In the meantime, cognitive-behavioral interventions are helpful. This
form of therapy, first used many years ago for depression (Beck, 1 967)
works by changing cognition, reversing negative views of the self, of the
world, and of the future.

ANXIETY DISORDER

A final category of psychiatric disorders that are common in children and

adolescents, (particularly those with learning disorders) is "anxiety disor-
ders." Anxiety disorders exist in several forms including: "separation anxi-
ety disorder," "avoidant disorder," "generalized anxiety disorder,"
"post-traumatic stress disorder" (PTSD), and "obsessive-compulsive disor-
der" (OCD).
"Separation Anxiety Disorder" consists of an abnormal fear of being
separated from mother, the home, or a familiar environment. Although
separation fears are considered normal in toddlers, they are not normal
in school aged children. "Separation Anxiety Disorder" can be mani-
fested by a refusal to go to school, a refusal to sleep over at somebody's
house, by not letting the parents leave the house, or by requiring parents
to sleep with the child. The term "school phobia" has been used for the
disorder, but that is not appropriate since these children do not have a
true fear of school.
Medication alone is usually not an effective treatment for "Separation
Anxiety Disorder". A behavioral intervention program is needed in order
to get these children to separate comfortably. However, anti-anxiety
drugs (i.e., Imipramine, or Xanax) can be beneficial in combination with
the behavioral program.
"Avoidant Disorder" is a disorder in which, (despite some close peer
relationships), there is excessive shyness, fear of social situations, and
fear of making friends. This condition definitely does not respond to
medication.
"Generalized Anxiety Disorder" is characterized by a wide range of
symptoms reflecting fears in a variety of different kinds of settings. This
condition is also not usually responsive to medication.
"Post-Traumatic Stress Disorder" is a reaction to a severe trauma, such
as witnessing a murder or gang violence. Medications such as Clonidine
 Pharmacological Interventions 201

and Propranolol and some antidepressants can decrease anxiety in chil-

dren with this disorder. However, these are adjunctive treatments. The
most effective intervention for this disorder is desensitization involving a
reenactment and rebuilding of the traumatic event.
"Obsessive-compulsive Disorder" (OCD) is an anxiety disorder charac-
terized by obsessional ideas or images and ritualistic, compulsive, and
repetitive behaviors. Typical symptoms include lining up objects or
counting objects; having excessive fears of germs or illnesses; and en-
gaging in excessive hand washing. the disorder is very difficult to diag-
nose in children, because they will recognize that their symptoms are
"crazy" and will be very secretive about them.
As recently as five years ago, it was believed that OCD was unrespon-
sive to medications. However, the advent of the serotoniri reuptake
blockers (i.e., Anafranil and Prozac) has dramatically altered the treat-
ment of OCD. These drugs do not cure OCD, but they make the condi-
tion substantially better. In combination with the psychotherapy, these
medications can help these children to live a relatively normal life.
Anafranil (or clomipramine) is particularly effective for OCD, having dra-
matic, striking effects on obsessive-compulsive behavior in approxi-
mately 80% of children. It is dramatically different from its parent
compound (Imipramine) which has no effects on obsessive-compulsive
symptoms.

REFERENCES
Baker, L., & cantwell, D. P. (1992). Attention deficit disorder and speech/language disor-
ders. Comprehensive Mental Health Care, 2(1), 3—16.
Beck, A. 1. (1967). Depression: Clinical, Experimental & TheoreticalAspects. New York: Har-
per & Row.
Beck, 1., Langford, W. S., Mackay, M., & Sum, C. (1975). Childhood chemotherapy and later
drug abuse and growth curve: A follow-up study of 30 adolescents. American Journal
of Psychiatry, 132, 436-438.
Bell, L., & Bloomquist, M. L. (1991). Cognitive-behavioral therapy with ADHD Children:
child, family, & school interventions. New York: Guilford Press.
CantweU, D. P. (1980). A clinician's guide to the use of stimulant medication for the psychiat-
ric disorders of children. Journal of Developmental & Behavioral Pediatrics, 1(3),
133—140.
Cantwell, D. P. & Baker, L. (1992). Attention deficit disorder with and without hyperactivity:
a review and comparison of matched groups. Journal of the American Academy of
Child and Adolescent Psychiatry, 31, 432-438.
Chess, S. (1979). Development theory revisited: Findings of a longitudinal study. Canadian
Journal of Psychiatry, 24,101—112.
Clampit, M. K. & Pirkie, I. B. (1983). Stimulant medication and the hyperactive adolescent:
Myths and facts. Adolescence, 28, 811—822.
202 Dennis P. Cantwell and brian Baker

Cohen, D. J., Riddle, M. A., & Leckman, I. F. (1992). Pharmacotherapy of Tourette's syn-
drome and associated disorders. Psychiatric Clinics of North America, 15(1),
109-129.
Dulcan, M. K. (1990). Using psychostimulants to treat behavioral disorders of children and
adolescents. Journal of Child and Adolescent Psychopharmacology, 1, 7—20.
Hechtman, 1., Weiss, C., & Perlman, T. (1984). Young adult outcome of hyperactive children
who received long-term stimulant treatment. Journal of the American Academy of
Child Psychiatry, 23, 26—1269.
Huessy, H. R. (1992). Comorbidity of attention deficit hyperactivity disorder and other dis-
orders (letter). American Journal of Psychiatry, 149(1), 148—149.
Hunt, R. D., Cohen, D. J., Anderson, C., & Clark, L. (1984). Possible change in noradrenergic
receptor sensitivity following methylphenidate treatment: Growth hormone and
MHPG response to clonidine challenge in children with attention deficit disorder and
hyperactivity. Life Sciences, 35(8), 885—897.
Kavale, K. (1982). The efficacy of stimulant drug treatment for hyperactivity: A meta-analy-
sis. Journal of Learning Disabilities, 15, 280—288.
Satterfield, J. H., Hope, C. M., & Schell, A. M. (1982). A prospective study of delinquency in
110 adolescent boys with attention deficit disorder and 88 normal adolescent boys.
American Journal of Psychiatry, 139, 795—798.
Shaywitz, S. E., Shaywitz, B. A., Fletcher, J. H., & Escobar, M.D. (1990). Prevalence of reading
disability in boys and girls: Results of the Connecticut longitudinal study. Journal of the
American Medical Association, 264, 998-1002.
Shaywitz, S. E., Shaywitz, B. A., Schnell, C., & Towle, V. R. (1988). Concurrent and predictive
validity of the Yale Children's Inventory: an instrument to assess children with atten-
tional deficits and learning disabilities. Pediatrics, 81(4), 562—571.
Swanson, J., Simpson, S., Agler, D., Kotkin, R., Pfiffner, 1., Bender, M., Rosenau, C., Mayfield,
K., Ferrari, 1., Holcombe, L., Prince, D., Mordkin, M., Elliot, J., Minura, S., Shea, C., Bon-
forte, S., Youpa, D., Phillips, 1., Nash, L., McBurnett, K., Lerner, M., Robinson, T., Levin,
M., Baren, M., & Cantwell, D. (1990). UCI-OCDE school-based treatment program for
children with ADHD/ODD. In C. N. Stefanis, A. D. Rabavilas, & C. R. Soldatos (Eds.),
Psychiatry: A world perspective, (vol. 1, pp. 1107—1012). Elsevier Science Publishers
B. V.
LECTURE 9

Joan T. Esposito
Dyslexia Awareness and Resource Center,
Executive Director
California Learning Disabilities Association,
Past President

THE EMOTIONAL
AND EDUCATIONAL
CHALLENGES OF DYSLEXIA
AND ATTENTION DEFICIT
DISORDER: ONE STORY

"I feel trapped and alone in a shell of dark sadness, surrounded

by laughter / always feel alone---trapped in a room of darkness."
—Ten-year old boy
v4th learning disabilities
204 Joan T. Esposito

Introduction by Richard L. Goldman

For our last seminar, our speaker will address the challenges of having dys-
lexia and attention deficit disorder.
As an adult with attention deficit disorder and dyslexia, and whose son
also has dyslexia, Ms. Esposito brings a unique perspective. She could
barely read until she was 44 years old and has experienced all the frustra-
tions and challenges of dealing with a learning disability.
She was president of the California Learning Disabilities Association
for 2 years and previously served as their Governmental Affairs Chairper-
son. She also has received numerous national awards, including a nomi-
nation as one of the President's Thousand Points of Light. Ms. Esposito is
the Founder and Executive Director of The Dyslexia Awareness and Re-
source Center in Santa Barbara. The center provides information and
support services to dyslexics of all ages. Most importantly, she has
turned her personal experience into a crusade by being a committed ad-
vocate at the state and national level.
It is my pleasure to introduce Ms. Joan Esposito.

Ms. Joan Esposito

Because I have both dyslexia and attention deficit disorder, I need to read
my presentation to you. Because of my learning disabilities, I have trouble
retrieving information quickly from my memory, and I have great difficulty
organizing and expressing my thoughts in sequence. I may start at the end
of a story, jump to the beginning, and end in the middle. Often I leave out
important details that I feel I have already shared, but, somehow, the
words have remained in my mind.
Eight years ago, my reading proficiency was at a fourth grade level. My
spelling was atrocious; I had first grade punctuation and grammar skills. I
was not identified as dyslexic until age forty-four after my seventeen-
year-old son was diagnosed with dyslexia and attention deficit disorder. I
grew up in Liverpool, England after World War Two. I was the fifth of six
children. My father had dyslexia, while my mother showed no signs of
learning disabilities. Although undiagnosed, several members of my fam-
ily have symptoms of learning disabilities.
"When you walk through a storm hold your head up high and don't be
afraid of the dark." I sang these words from a popular song over and over
to myself when I was a teenager. I lived in a storm all of my life until I
learned at age forty four that my reading and spelling problems were the
result a condition called dyslexia. As a young child in England, the time
 Challenges of Dyslexia and ADD: One Story 205

that I spent attending classes and attempting to learn was literally hell.
Every morning, I woke up sick to my stomach at the thought of school. I
could not understand why my parents made me go to school every day
and struggle. I simply could not learn—no matter how hard I tried. My
teachers could not teach me.
Because I did not learn like many of my classmates, I did not socialize
with them either. How could I? I could not read or spell like them. I was
constantly teased by them. I did not play with the others because I felt
different from them. I could not understand or explain why I felt differ-
ent, I just did! Even without a name for the difference, I knew deep inside
that I was different. Each day I sat in class and prayed that the teacher
would not ask me to read out loud. I went home from school at night and
cried myself to sleep because I did not understand why I could not read
or spell as well as my classmates. As I tried to spell and write legibly I told
myself:

"1 don't look retarded but I must be slightly retarded."

"Maybe I have brain damage."
"The teachers say I can spell if I try harder, but I do try and it does not
work."
"Maybe I can't spell because I was born during the war while they
were bombing Liverpool and somehow the noise of the bombs affected
the way I can learn."
"Maybe I can't spell because I am the fifth of six children and they got
all of the brains from my parents and left none for me."
"I must never have any children in case they inherit my damaged
brains."
"Maybe I will die before I leave school and then I will not have to spell."

I spent hours alone in my room, trying to figure out how to hide my read-
ing and writing problems from my family and friends. I lied and cheated
my way through school.

At the age of fifteen I went to work in a cigarette factory, brushing floors.

At seventeen I left home and moved to London, where I worked as a
chambermaid in a West End hotel, until a friend gave me a job in his office.
Throughout my life my jobs all were given to me by close friends. I was
able thus to avoid filling out job applications. I came to America as a
nanny in 1963, when I was twenty years old. With the help of a friend who
read the textbook to me, I later became a manicurist. In 1968 I married a
literary agent from Beverly Hills. Our marriage lasted eleven years. During
206 Joan T. Esposito

that time I entertained some of the top studio executives, directors, pro-
ducers and actors in Hollywood.
The first week I was married, my husband told me that we were going
to have some of his clients to our home for dinner: German actress Elke
Sommers, her husband, Joe Hyams, and Elliot Silverstein, who had just
successfully directed "A Man Called Horse" with Michael Cain. I con-
fessed to my new husband that I was not a good cook, but he directed
me to several cookbooks in the kitchen. What I didn't confess was that I
couldn't read them. Somehow I managed to talk my new husband into
cooking the meal. I helped and watched what he did, and soon learned
how to cook what he could cook. To keep my reading problem a secret,
however, I took a French cookery class. I watched the chef prepare a
meal, then I went home and immediately cooked the same meal to re-
member it. To reinforce my memory I cooked and served the same meal
over and over. Because of all the butter and cream sauces in French
cooking, my husband developed a problem with gout. I now can smile at
my contribution to his problems with gout you, and will see why as my
story continues.
During the first part of my marriage I took dozens of tennis lessons. I
had a strong serve, my coordination was good, and I was able to hit the
ball where I wanted it. But, I could never remember the score or where I
was supposed to stand. Elke Sommers and I had became good friends,
and she was also taking tennis lessons. One day, as I was watching her
take a lesson, she asked me to play a game with her. I quickly replied that
I had given up my lessons and that she needed some one with more ex-
perience. I then had to stop taking lessons so that she would not discover
my lie.

One success for me has been bargain hunting for antiques. Over the
years, people have given me over forty books on antiques, but, of course,
they were of no use to me. I learned by going to antique auctions. I went
to a preview the day before each auction, where I would touch and feel
the pieces and ask the auction attendant questions. I would then attend
the auction. By watching the buyers in the audience bid and by writing
down the prices at which the antiques went, I was able to remember both
the antiques and their prices. I then could go to the antique shops and
compare the prices.
Because of my problems due to undiagnosed dyslexia, I missed many
business opportunities over the years. For example, Elke admired the an-
tiques I bought, and asked me to go to Europe to buy antiques with her
money and split the profits with her. I told her I could not leave my young
 Challenges of Dyslexia and ADD: One Story 207

son. What I could not tell her was that I could not read or write well
enough to fill out the forms to get antiques back into this country. As a
result of my learning disabilities I often get disoriented when I travel to
new towns; even walking through new airports and catching a plane can
be confusing for me. Not only the antiques would have been lost in Eu-
rope: I would too. Liza Minelli also admired my decorating talents. She
tried to talk me into decorating her home. But once again I had to lie. I
said I was too busy entertaining my husband's clients and looking after
our young son.
One afternoon, I was sitting in our den with Liza, when my five-year-
old son came in with a container of popcorn in a tinfoil dish. He wanted
me to cook it on the stove top. I knew I could not follow the directions on
top of the popcorn container. My husband, who usually made the pop-
corn, was in the other room talking business with Liza's future husband,
Jack Haley, Jr. So I could not disturb him. I made several excuses to my
young son, but he was not going to let me off that easily. When Liza saw
that I was not responding to Joel, she picked him up and carried him and
the popcorn into the kitchen. I did not dare follow them, in case she gave
the popcorn back to me. So I sat in the den feeling stupid and sick to my
stomach. Soon I could smell something burning, so I ran into the kitchen.
Joel was sitting on the kitchen counter, and Liza was singing and dancing
around the kitchen for him, whlle the popcorn burned on the stove.

On two occasions I was a guest in Chariton Heston's home, and I met him
several times at the studios and at social functions. I found him a warm
and wonderful person but tried my best to avoid talking with him because
of his dry sense of humor. As a resuk of my learning disabilities, I don't
always understand jokes or anyone with a dry sense of humor. Telling
jokes was Chuck's way of making me feel comfortable whenever we met,
but his humor, ironically, had the opposite effect on me.
Before my dyslexia was diagnosed and I understood how I function as
a person with dyslexia, I always felt uncomfortable at parties and in other
social situations. I would avoid parties like the plague. But on one occa-
sion, I allowed myself to be talked into going to a Tupperware party at a
friend's house. Towards the end of the party we were to play a game for
which we had to write down five nouns. I quickly excused myself and
-went to the bathroom. I walked back and forth, looking in the mirror, and
told myself how stupid I was. I had been told over and over what a noun
was; why could I not remember? I felt sick to my stomach. I stayed in the
bathroom as long as I could and hoped that they had finished their game
without me. I came out of the bathroom to find they had waited for me,
208 Joan T. Esposito

so that I would not miss the chance to win the prize, a plastic cup. I can't
remember how I escaped, but I can assure you I never went to another
Tupperware party.
I worked hard and became very clever at covering up my problems
with language, but it took a toll on my health. I developed severe hypo-
glycemia. Several times, I was admitted to the hospital for violent stom-
ach pains and headaches. Each time, after numerous tests showed no
physical cause for the pains, I was released from the hospital without a
diagnosis.
After several years of struggling to entertain clients, I was thrilled at the
idea that our family would leave Beverly Hills for Santa Barbara. We had
no clients or friends in Santa Barbara, and there I could hide away from
the world. We bought a large, old, Spanish home. For the first six months
in Santa Barbara I was happy. I spent the time doing things I loved to do,
things I was gifted in: gardening, remodeling and decorating our home.
Then, one day, my son's teacher asked me to help in his second grade
classroom. I thought I would be able to work with the children on their
art projects or just watch over them for the teacher. But the teacher
asked me to help the children with their spelling and reading. I made an
excuse to leave the classroom, and I never went back.

At this point in life I became a recluse. I would not answer the telephone. I
very seldom left the house. When friends came from Beverly Hills to visit, I
would stay in my bedroom and pretend that I was ill. I saw very few of our
old friends. More and more, I withdrew into myself and became deeply
depressed. I knew that something was wrong with me, but did not know
where to go to get help. I went to a doctor and a counselor, and they both
blamed my withdrawal and depression on my lack of an education, my
low self esteem and my domineering husband. The doctor's solution was
to put me on a heavy dose of anti-depressants, which made me sleep
most of the day.
My ex-husband, my son's father, also has severe symptoms of dyslexia
and attention deficit disorder, although he has not been formally diag-
nosed. He brought the anger, frustration and pain that he had experi-
enced in school into our marriage, and I was the recipient of his violent
temper and mood swings. I was not unlike other women, unable to ac-
quire an education because of their dyslexia, afraid to leave an abusive
husband for fear of not being able to get a job to support their children.
After eleven years of marriage I could no longer take his physical abuse,
and it was starting to affect our son. Somehow, I worked up the courage
to file for a divorce.
 Challenges of Dyslexia and ADD: One Story 209

During divorce proceedings, our home sold for over one million dol-
lars, and we had another million and a half in assets. From the day my
nine-year-old son and I moved out of our home, we were homeless off
and on for six years. Fourteen months from that day we found ourselves
on food stamps. My husband had handled all of the finances and bank
accounts.
My husband and his lawyers used my lack of education against me in
court to try to gain custody of our son. The probation officer in our child
custody case reported to the court that he found that "although Joan is
uneducated, I find her quite intelligent." Some of the most humiliating
experiences of my life came when I sat in depositions and courtrooms
full of strangers while my illiteracy and lack of a formal education was
brought up over and over again in reference to my gaining custody of our
son. Testimony on my illiteracy was used over a seven year period, in
over two hundred court appearances.
One year into the divorce proceedings my husband filed bankruptcy
and he put my assets into his bankruptcy. He left the country with the
rest of our assets and left me to pay the taxes, his creditors and his legal
expenses from before and after our separation. He moved to England,
where he met his next wife. She was a former Russian ballerina with the
Royal School of Ballet in London. He bought a Manor House that had
belonged to the late Lord Butler. He drove a Rolls-Royce and traveled
around the world with members of Lord Sainsbury's family. He sent post-
cards to our ten-year-old about his travels abroad and his hunting week-
ends at Lord Sainsbury's country estate. Meanwhile, I was living in Santa
Barbara. I did not have the necessary skills to get a job with a livable
wage, so I cleaned hotel rooms to support us. The salary I made was not
enough to even pay our rent, but we were able to survive with the help of
friends. (You can see now why my ex-husband deserved gout.)
At one point in the bankruptcy court proceedings, when I had no law-
yer, the judge said I had to write a letter. I jumped up and said, "Your
Honor, I don't know what it is, but I have problems writing letters. I need
a dictionary to write!" He was not at all happy with my interruption and
ordered me to write the letter. What the judge heard me say and what I
thought I had said were totally different. I thought I had said, "Your Hon-
or, I can't spell. My hand writing is unreadable. I do not know anything
about grammar. It is very difficult for me to get my thoughts down on
paper in sequence, and I can't find the correct spellings of words in a
dictionary. I own seventeen dictionaries and can't find one that works for
me." I truly believed that I had explained my problem clearly to the
210 Joan T. Esposito

judge, because the thoughts were in my head. But they simply did not
come out the way I thought they did. It was only when I read the court
transcript, years after the divorce was final, that I realized I had not fully
explained my language problem to the judge.
Besides my lawyers and my ex-husband, only two friends knew about
my spelling and writing problems. I spent most of my days and evenings
writing letters to my lawyers by hand. I rewrote my letters over and over; I
made mistakes copying from one page to another. My hand and brain
would get tired. The physical writing on each line and page looked differ-
ent: I used print, script, upper and lower case letters, all in one sentence.
I wrote descriptions of myself in the first, second and third person, as I
still do. Writing was tiring and time consuming. I was constantly on the
telephone to my two friends, asking them to spell words for me. After
months of writing by hand I bought a typewriter for ten dollars at the
swap meet. I was able to write longer letters, but they still had commas
and periods wherever I felt like putting them, and paragraphs were non-
existent.
Because of the custody fight over our son and my fear of losing him, I
gathered up courage and drove to the Santa Barbara City College to en-
roll in an English class. I was sent into a small building where I was given a
test. The questions on the test directed me to find such things in a sen-
tence as the object, the indirect object, the clause, or the prepositional
phrase. I could not understand what an object had to do with grammar.
An object to me was a thing. At that point I could not even pronounce
the word "prepositional phrase." Santa Claus was the only meaning I
could get from the word "clause," and "prepositional" was beyond my
vocabulary. I slipped out of the testing lab when no one was looking and
never returned to finish.

A few months after I married my new husband Les, we discovered that

both my son and I had dyslexia and attention deficit disorder. Les helped
me enroll for classes in the learning disabilities department at Santa Bar-
bara City College. I was forty-four years old, functionally illiterate and full
to the brim with low self esteem. At college I discovered that I could learn
how to read and write and met other people who function like I do. Like
me, my classmates had lived with a lifetime of pain. Some of the men
would bang their fists on their desks out of frustration if they could not do
their work. Others would get angry if another student laughed at their mis-
takes. They were not past the pain they had experienced in grade school
when their peers or teachers teased them. Students expressed anger over
their wasted years in grade school and high school. We questioned our
 Challenges of Dyslexia and ADD: One Story 211

teachers at the college: why could they teach us the reading, spelling, writ-
ing, and math that we could not learn in grade school? You could hear the
anger in some students voices when they questioned the teachers: "WHY
DIDN'T WE HAVE TEACHERS LIKE YOU IN OUR SCHOOLS WHEN WE
WERE KIDS?!"
It was because of my own experiences and those of other students in
my college class that I started the volunteer work I have been doing ever
since. I approached our Santa Barbara newspaper with an article on dys-
lexia. After the article appeared in the paper, I was overwhelmed with
calls from parents asking me to help them advocate for their children
with dyslexia. After three years of working out of our home, in 1990, my
husband Les and I founded the Dyslexia Awareness and Resource Cen-
ter, which is a non-profit organization in Santa Barbara. We have assisted
over six thousand clients, and all the services at the Center are free. I at-
tend Individual Educational Plan (IEP) meetings with parents, expulsion
hearings, court hearings and probation hearings for juvenile delinquents
with learning disabilities. I meet with employers and teach them about
dyslexia and how it affects employee performance. We train groups of
counselors on the nature of learning disabilities. We have a seventy-thou-
sand dollar library of books, teacher training tapes, dyslexia reading pro-
gram videos, and video and audio tapes on learning disabilities, dyslexia,
attention deficit disorder, and Tourette's Syndrome. The Center is the
only one of its kind in the nation.

I can't finish my story without telling you something about my son, Joel, of
whom I am so very proud. When he was seventeen, we discovered that he
had dyslexia and attention deficit disorder. After years of struggling, he
managed to graduate from high school. His report cards commented that
• "he needs to pay attention to written work, keep papers neat and
show the depth of thinking that he indicates verbally";
• "sloppy and disorganized";
• "the weakness of his handwriting will probably preclude his joining
the honors section of U.S. History next year"; and
• "your habits have shown every sign of being quite lazy; the result is
that you are full of intriguing thoughts, insight and a fine vocabulary
which you can only express in poor spelling, poor punctuation and
sentence fragments or run-ons."
After high school my son entered the University of California in Santa Bar-
bara with the most valuable tool in a dyslexic's life, a computer. He be-
212 Joan T. Esposito

came a reporter and assistant editor for the university newspaper. He also
wrote articles for local newspapers.
Joel has just turned twenty-three and is presently a freelance reporter
in Yugoslavia, where he has been living for the last two and a half years.
His news articles on Sarajevo are published in Newsweek, The London
Times, The Irish Times, The Washington Post, The San Francisco Chronicle,
The Toronto Sun, The Miami Herald, The San Diego Chronicle and numer-
ous other national and international newspapers. His articles have been
published in Life, People and Rolling Stone magazines, as well as several
European magazines. He also reports live from Sarajevo for CNN televi-
sion and Sky Television News in Europe.

I would like to close today with a quote from a man whom I admire for his
work on behalf of learning disabled juvenile delinquents. judge Jeffrey H.
Gallet is a judge in the Family Court in New York state. Judge Gallet also
struggled in school with dyslexia. He said, "IF YOU CANNOT READ
THERE ARE ONLY TWO WAYS TO MAKE A LIVING—THE WELFARE
SYSTEM OR CRIME—AND CRIME HAS MORE STATUS."
I would like to thank you for listening.

POSTSCRIPT

Before I finish, I just want to tell you how important it was for me to discov-
er that I had learning disabilities. The labels I gave to myself as an unin-
formed and innocent child were debilitating. The diagnosis of dyslexia
freed me to fulfill my dreams and become a functioning adult. I needed
the appropriate label in order to find a teaching method that had worked
for other people with dyslexia. Although I have several learning disabili-
ties, including attention deficit disorder, the one that affected me most se-
verely was dyslexia. I could read words that I had learned through whole
word recognition, but with new words I struggled to match the sound to
the written symbol on the page. If you can't read, how do you learn about
your other learning disabilities?

Note: This chapter is part of a larger work in progress.

 RESOURCES

ORGANIZATIONS
Association of Educational Therapists (AET)
14852 Ventura Blvd., Suite 207, Sherman Oaks, CA 91403
(818) 788-3850 Fax (818) 380-6896
Children and Adults with Attention Deficit Disorder (C.H.A.D.D.)
499 Northwest 70th Street, Plantation, FL 33317
(305) 587—3700

Council for Exceptional Children (CEC)

1920 Association Drive, Reston, VA 22091
(703) 620-3660
Council for Learning Disabilities
P.O. Box 40303, Overland Park, KS 66204
(913) 492—8755

Dyslexia Awareness and Resource Center

928 Carpinteria Street, Suite 2
Santa Barbara, CA 93103
(805) 963-7339
Etta Israel Center
6505 Wilshire Bive, Suite 503, Los Angeles, CA 90048
(213) 852—3222

Learning Disabilities Association (IDA)

41 56 Library Road, Pittsburgh, PA 15234
(412) 341 —8077

The Learning Disabilities Network

72 Sharp St., Suite A—2, Hingham, MA 02043
(61 7) 340—5605

National Center for Learning Disabilities (NCLD)

381 Park Avenue South, Suite 1420, New York, NY 10016
(212) 545—7510

Parents Educational Resource Center

1660 South Amphlett Blvd., Suite 200
San Mateo, CA 94402
(415) 655-2410 Fax (415) 655-2411
214 Resources

Orion Dyslexia Society

Chester Building, Suite 382, 8600 La Salle Rd, Baltimore, MD 21204
(410) 296-0232
The Rebus Institute
1499 Bayshore Blvd., Suite 146, Burlingame CA 94010
(415) 697-7424

PUBLICATIONS

ADHD Report, A bimonthly newsletter for clinicians edited by Dr. Barkley

with contributions from leading clinicians and researchers. Call Guil-
ford Publications at (800) 365—7066 to subscribe.
Answers to Distractions, by Edward M. Hallowell, M.D., and John J. Ratey,
M.D., Pantheon Books, New York, 1994.
Attention Deficit Hyperactivity Disorder: A Handbook for Diagnosis
and Treatment, by R. A. Barkley, Guilford Press, 72 Spring St., New
York, NY, 1990.
Dr. Larry Silver's Advice to Parents on Attention Deficit Hyperactivity
Disorder, by Larry Silver, M.D., American Psychiatric Press, Inc.,
Washington, DC, 1993.
Driven to Distraction, by Edward M. Hallowell, M.D., and John J. Ratey,
M.D., Pantheon Books, New York, 1994.
I Can Learn, A handbook for parents, teachers, students. California De-
partment of Education, Special Education Division, Sacramento,
1994.
Keeping A Head in School, by Dr. Mel Levine, Cambridge, MA, Educators
Publishing Service, 1 990.
The Learning Disabled Child: Ways That Parents Can Help, by Suzanne
H. Stevens, N. Carolina, John F. Blair, 1985.
Learning Disabilities — A Family Affair, by Betty B. Osman, New York,
Warner Books, 1979.
The Misunderstood Child, by Dr. Larry B. Silver, New York, McGraw-Hill,
1984.
No Easy Answers The LD Child at Home and School, by Sally L. Smith,
Toronto, Bantam Books, 1980.
 Resources 215

No One to Play With, by Betty B. Osman, New York, Warner Brooks,

1982.

Reading. Writing, and Rage, by Dorothy Fink Ungerleider, Rolling Hills Es-
tates, CA, Jalmar Press, 1 985.
Smart Kids With School Problems, by Priscilla 1. Vail, New York, e.P. Dut-
ton, 1987.
Succeeding Against the Odds, How the Learning Disabled Can Realize
their Promise, by Sally L. Smith, New York, Jeremy Tarcher, Perigree
Books, 1991.
Taking Charge of ADHD: The Complete Authoritative Guide for Parents,
R. A. Barkley, Guilford Press, New York, 1995.

VIDEOTAPES

ADHD in Adults
ADHD in the Classroom
ADHD: What Do We Know?
ADHD: What Can We Do?
Russell A. Barkley, Ph.D.
Stonebridge Seminard, 1 992, (508) 836-5570
Guilford Publications, 72 Spring St., New York, NY 10012
(800) 365-7006
How Difficult Can This Be?
Understanding Learning Disabilities (F.A. T. City)
Richard LaVole, PBS Video, 1989. 800 344-3337, Fax (703) 739-5269
I'm Not Stupid
Gannett Broadcasting, Learning Disabilities Association
4156 Library Road, Pittsburgh, PA 15234 (412) 341-1515
Learning Disabilities and Social Skills:
Last One Picked, First One Picked On
Richard Lavoie, PBS Videos, 1994. (800) 344-3337, Fax (703) 739—5269
We Can Learn:
Understanding and Helping Children with Learning Disabilities
National Center for Learning Disabilities (NCLD), 1989.
(212) 545—7510, Fax (212) 545—9665
 INDEX

A Apraxic-dyspraxic syndrome,
157—158
Association of Children with Learn-
Abusers, 138
Academic difficulties, 4 ing Disabilities (ACLD), 92
remediation of, 147-148 Astereognosis, 162, 164
Academic reorientation, 52—54 Attention deficit disorder (ADD),
Academic support services, 33 2, 3, 143, 190—193,
Acalculia, 164—165 204-2 12
Activities outside the home, interventions for, 193—194
128—129 medications for, 193-198
Adjustment disorder, 74 Attention deficit disorder, residual
Admonishment of learning dis- state, 193
abled children, 135 Attention deficit disorder with hy-
Adults and attention deficit disor- peractivity (ADDH), 191
der, 192-193 Attention deficit disorder without
Advocacy of learning disabled chil- hyperactivity (ADDW), 191
dren, 16—19, 125 Attention deficit hyperactivity dis-
Aggression, 171—172 order (ADHD), 4-5, 70-73
Agnosia, 161 classification of, 81
Allergies and hyperactivity, 192 treatment of, 84-85
Amitriptyline, 197 Attentional problems, 190
Amphetamines, 195, 196
Attorney type behavior, 1 71
Anafranil, 201
Attribution theory, 121
Analytic method of phonics,
116-117 Auditory agnosias, 161
Anger, 138-139 Auditory distractibility, 25
Anhedonia, 199 Auditory figure-ground problems,
Anti-anxiety drugs, 200 8,45
Antidepressants, 201 Auditory input problems, 6-7
Anxiety disorders, 69, 200-201 Auditory lag, 9
Anxiety reduction, 52 Auditory perception problems, 7,
Aphasia, 46 8-9,16,18
Apoxia and coordination prob- Auditory processing in dyslexics,
lems, 149 36
218 Index

Auditory short-term memory, Chinese readers, 101-104

12—13, 18—19 Choreas, 146
Avoidance behaviors, 49, 52-53, Chores for disabled children,
200 14-15
of clumsy children, 169—1 72 Circle back technique, 53—54
Clonidine, 198, 200
B Closed brain injuries, 1 50
Clumsiness. See Coordination
Babies, drug addicted, 82-84 problems
Balance, difficulties in, 10, Clumsy child syndrome, 147
153—154 Clumsy children. See Coordination
Ball throwing, 178-179
problems
Bedtime problems, 138 Coach/interpreter role of parents,
Benign hypotonia, 154 50—51, 54-55
Blaming by parents, 132—133 Code emphasis approach to pho-
Board games as learning aids, 49 nics, 116—117
Body agnosias, 161 -165 Cognitive behavioral therapy for
Books-on-tape, 118 attention deficit disorder chil-
Brain
dren, 193
abnormalities of, 29, 80, 120 Colic and attention deficit disor-
activity of, 40—4 1
der, 192
and oxygen deprivation, 149
Comedic behaviors, 1 71
trauma, 150
Comic strips as a learning aid, 56
Break-in period for medications,
197
Communication, 131
Co-morbidity of learning disabili-
British Social Adjustment Guide,
167 ties, 62—86, 192
Buccofacial apraxia, 1 57
Compensatory behaviors of
clumsy children, 169—1 72
Bupropion, 198
Compensatory verbalization, 1 71
Computational problem with
C
grammar, 34
Card games as learning aids, Conduct disorder, 71 —74
48-49 Conformity by chilren, 20—2 1
Careers of dyslexics, 3 5—36 Contemporary phase of learning
Case study research, 92—93 disability research, 89, 90,
Ceiling effects of test taking, 100 92
Cerebellar syndrome, 152—154 Coordination problems
Cerebellum, 151 -154 causes of, 149—151
Children with Specific Learning history of, 146-149
Disabilities Act, 92 incidence of, 145—146
 Index 219

of the learning disabled, Dyslexia, 4, 17—18, 35—41,

142—18 1 88-121, 204-212
subtypes of, 151-152 and brain abnormalities, 120
Crack cocaine and coordination and careers, 3 5—36
problems, 1 50 cure of, 119—120
Criticism, 56—57 definition of, 95
Cylert, 195, 196 incidence of, 95-101
longitudinal studies of, 32—35
D and motor awkwardness,
145-147
Decoding words, 31, 35, 107—113 origin of, 28-29
Deep dyslexia, 93 subtypes of, 93-95
Demand language disability, 13, testing for, 120—121
16 Dyslexics, 2, 104—11 5
Demoralization, 199—200 and decoding words, 109-113
Denial, state of, 131—132 and parental involvement,
Depression, 69, 74-75, 80-81, 117—119
199 and reading skills, 107—109
Developmental apraxia, 143 teaching techniques for,
Developmental coordination disor- 115—117
der, 149 Dysphonetic dyslexia, 93—95,
Developmental expressive writing 103—104, 110
disorder, 149 Dyspraxia, 156—158, 162
Developmental lags, 113-114 remediating of, 1 76
Dexedrine, 195, 196 Dysthymia, 74—75
Digital agnosia, 162, 164-165
Disadvantaged children, 3 E
Discipline, 21
Disuse syndrome, 180 Education programs and motor
Dopamine, 196, 197 coordination improvements,
Drug ingestion and coordination 174—181
problems, 150 Elavil, 197
Drug vacation, 84, 196—197, 198 Emotional instability and motor im-
Dyscalculia, 89 pairment, 167-168
Dyseidetic dyslexia, 93—95, Emotional problems, 3, 125—139
103-104 of clumsy children, 166—1 72
Dysgosia, 161 of dyslexic children, 121
Dysgraphia, 44-45, 46, 49, of learning disabled children,
158—159 50—5 1
nonspecific, 1 58-1 59 Emotional/behavioral disorder
specific, 1 58 (EBD), 82
220 Index

Emotionally disturbed children, Gross motor skills, 14, 16

64-66 Group therapy, 86
Empathy, 134—137 Growth suppression and stimu-
Encouragement, 135 lants, 196, 197
Envy, 130—131
Examinations, taking of, 132 H
Exploitation of parents by children, Hearing losses in dyslexics, 36
56
Homework, 21-22
Extraction difficulties, 10, 11
Hopping tests, 153
Eye movements Horizontal faculties, 114
erratic, 159—160 Hyperactivity and medication,
problems in, 152 177—1 79
Hyperactivity symptom cluster,
F 189
Hyperkinetic reaction of child-
Faculty psychology, 114 hood, 4
Familial influences and coordina-
Hyperlexic reader, 108
tion problems, 1 51
Hypertonicity, 155—156
Family Hyperverbalization, 1 71
and chores for children, 14-15
Hypotonic syndrome, 154-155
and learning disabilities, 19—20,
Hypoxia, 149-150
124-139
support and dyslexia, 33
Fenfluramine hydrochloride, 195
Figure/ground perception, 76—77 Imipramine, 197
Fine motor skills disability, 14 lmpulsivity problems, 191
Foundation phase of learning dis- Inconsequence and motor impair-
ability research, 89, 90, 91 ment, 167
Friend making abilities, 58 Individuals with Disabilities Educa-
tion Act, 67
G
Infantilization, 170—171
Inner box, 46
Gender differences in coordina- Input disabilities, 6—7
tion problems, 145 Integration difficulties, 10—12
Generalized anxiety disorder, 200 Integration phase of learning dis-
Genetics and phonological skills, ability research, 89, 90, 92
32, 34, 36 Intellectual assessment test, 24
Girls and motor activities, 1 73, Intelligence tests, 33, 79, 120
180 and dyslexics, 3 7—38
Global disorders, 76, 77 Internal fidgetiness, 193
Grammatical abilities, 34, 39—40 Internalizing disorder, 74
 Index 221

IQ tests. See Intelligence tests Limb agnosias, 164

Isle of Wight study, 96—101 Linguistic comprehension,
107-109, 116
J Lithium, 199
Locomotor activities, improvement
Jobs and dyslexics, 48 in, 179
Logographic system, 102
K
Long-term memory, 12
Kinesthetic awareness, 162, 164
lack of, 153 M
L Magnesium pemoline, 195
Manual graphic syndromes,
Language, comprehension of, 30 158—159
Language difficulties, 37, 77 Mathematical difficulties, 89
Learned helplessness, 1 55, and coordination problems,
1 70—171 164-165
Learning disabilities, 4—5, 64—66 and dyslexics, 38—39
and attention deficit hyperactiv- Matthew effects, 114—115, 116
ity disorder, 70—73 Meaning emphasis method of
and conduct disorder, 74 phonics, 116
and coordination problems, Medication
142—18 1 for motor coordination disor-
cures of, 22 ders, 177—1 79
and depression, 74-75, 80-81 for psychiatric disorders,
diagnosis of, 23—24, 67, 72—74, 188-201
79 Memory, 12—13
and drug addicted babies, Mental health services, 82
83-84 Mentally retarded, 3, 64-66
and dyslexia, 95-96 Methylphenidate, 195, 196
explanation of, 58 and hyperactivity, 1 77
and family dynamics, 124—139 Minimal brain damage, 3
and parents' help, 2, 5—6 Minimal brain dysfunction, 3
research, 89—92 Minimally brain damaged children,
subtypes of, 75-78 143
symptoms of, 6 Mixed group dyslexia, 93, 94,
Learning disability discrepancy for- 103-104
mula, 65, 72—73 Mixed syndrome, 160-161
Learning process, 45—47 Mood disorders, 199-200
Life disabilities, 5 Motor awkwardness. See Coor-
Life-time disabilities, 5, 10 dination problems
222 Index

Motor coordination problems, Orthographic tasks, 32, 101

172—174 Output difficulties, 1 3
Motor difficulties, 14, 41, 142, Oxygen deprivation and coordina-
145-146 tion problems, 149
Motor planning, 157—158
Motor soft-signs, 1 77—1 78 P
Movement disorders, 146-147
Movies as a learning aid, 56 Parental coaching, 50—51, 54-55
Multiple diagnoses, 189 Parents
Muscle memory, 45 and attention deficit disorder
Muscle planning, 9 children, 193
Muscle tone, flaccid, 154-155 and reading improvement of
children, 117—118
as source of help, 5—6, 50—5 1
N
Peer relationships with dyslexics,
Neurological abnormalities, 29, 47
80, 143, 146, 149—151, 157 Perception, 7
and sensory deficits, 162 Perceptual problems, 75-76,
Neurotransmitters, 194, 197 160-16 1
Non-intrusive mirroring, 137-138 PET scanners, 40
Non-learning disability pattern, 76, Phobias, school, 1 70
78 Phonecian readers, 101-104
Nonsense words, 94-95, Phonemes, 8, 116-117
110—113, 117 analysis of, 30—3 1
Non-verbal organization disorders, Phonic reading, 102, 116
75—76 Phonics, 31
Norepinephrine, 196, 197 teaching of, 115, 116—117
Phonological awareness, 93, 101
0 Phonological difficulties, 30—32,
34, 35—36, 113—114
Obsessive-compulsive disorder, Physical awkwardness. See Coor-
197, 201 dination problems
Ocular control problems, Physical education and motor
159-161 coordination improvements,
Off task behaviors, 1 97 174—181
One-minute counselor, 52-54 Physical fitness, 179—180
Oppositional/defiant disorder, 74 Pondimin, 195, 196
Organizational difficulties, 10, Poor readers
11—12,56 and decoding words, 109-113
improvement of, 48-49, 51 dyslexic, 98—115
Oroapraxia, 157 non-dyslexic, 88-12 1
 Index 223

Post-traumatic stress disorder, School phobia, 1 70, 200

200-201 School placement of attention def-
Pressure, 132 icit disorder children, 193
Problem solving, 138 Schools
Processing difficulties, improve- selection of, 58-59
ment of, 48-49 and training teachers, 85—86
Production deficits, 76, 77 Self-advocacy of children, 16—19
Propranolol, 201 Self-esteem, 125, 128, 135
Proprioception, 9 low, 166-167
Proprioceptive input, 45 Sensory integration, 9—10
Prozac, 198, 201 and motor coordination, 1 72
Psychiatric diagnosis, 78 Sensory-perceptual problems,
Psychiatric disorders and medica- 161—165
tion, 188-201 Separation anxiety disorder, 200
Psychotropic medication, Sequencing difficulties, 10—11, 1 5
188-201 Sequencing movements, 156—158,
174
R Serious emotional disturbance
definition of, 82
Reading difficulties, 34, 39,
diagnosis of, 68-70
88-12 1
Seriously emotionally disturbed
Reading retardation, general,
children, 64-66, 82
96-98, 101,104-115
Serotonin, 196, 197
Reading retardation, specific,
Serotonin uptake blockers, 201
96-98, 101
Services, qualitification for, 24
Reading skills, 98—117
Shame, chronic, 127
teaching of, 115—117
Shapes, differentiation in, 7
Reality, 57—58
Referral of learning disabled chil- Short-term memory, 30
dren, 191—192 disability of, 12—13, 14, 20
Reflective listening, 133—134 Siblings, 129—131, 138
Regular education initiative, 83 Social cues, 47, 55—56, 57, 126
Relaxation training, 156 learning of, 23
Rhyming words, 11 7, 118 Social maladjustment, 69—70
Ritalin, 84, 195, 196 Social skills, 23
Rivalry, 1 30 deficits, 81
training for attention deficit dis-
order children, 193-194
S
Social withdrawal, 155
Schizophrenia, 69 Sounds, differentiation in, 8—9
School difficulties, 4 Spatial agnosias, 163
224 Index

Spatial relationships, 47—48 Touch input, 9

Special education, 63—68 Tourette's syndrome, 198
Speech Transition phase of learning disabil-
articulation difficulties, 157 ity research, 89, 90, 91
phonological analysis of, 30 Trauma, 200-201
recording of, 40 Tremors, 153
Speech impaired children, 64—66 Tricyclic antidepressants,
Speech/language therapy for 197-198, 199
attention deficit disorder chil- Tumors
dren, 193 and coordination problems,
Splinter skills, 1 79 151
Spontaneous language, 1 3 and visual problems, 160
Sports participation of dyslexics, Tutors, 49
47-48
Startle reflex, 24-25 U
Stereognosis, 162
Unsteadiness, 153
Stimulants, 195-197
Strength, increase in, 1 76
Strephosymbolia, 91
V
Stretch reflex, 25 VAKT approach to dyslexia, 91 -92
Study habits, 129 Vascular accidents, 149—150
Stupidity and learning problems, Verbal organization disorders, 76,
20 77
Surface dyslexia, 93 Vertical faculties, 114
Symptom clusters, 189 Vestibular perception difficulty, 10
Synthetic method of phonics, Visual accommodation, 160
116—117 Visual figure-ground, 7—8
Visual input problems, 6
Visual perception, 7—8
T Visual perception problems,
159—16 1
Tactile agnosias, 163 and childhood activities, 14-16
Tactile deficits, 162
Visual processing problems,
Tactile perception, 9 38-39
Tegretol, 199 Visual short-term memory disabil-
Tension syndrome, 155-156 ity, 12
Tic disorder, 197-198 Visual-motor problems, 14, 16
Timing tasks, 146
Title recognition test, 39 w
Tofranil, 1 97
Tonic-neck reflex, 25 Walking through technique, 51
 Index 225

Wechsler Intelligence Scale for Word attack subtest, 110—112

Children-Revised (WISC), 46 Word blindness, 91
Wellbutrin, 198 Word finding problems, 30
Whole word reading, 102-104, Word processor as a learning aid,
116 49
Woodcock Johnson test, 24, 38, Working and dyslexics, 48
46,110—112