Understanding what you receive and knowing what else to ask for. Derek Griner, Ph.D., Michael Brooks, Ph.D., J.D., Edward Martinelli Jr., Ph.D. Definition of a Learning Disorder According to the DSM-IV, learning disorders are diagnosed when: a. The individual’s achievement on individually administered, standardized tests in reading, mathematics, or written expression are substantially below that expected for age, schooling and level of intelligence. b. The learning problems in Criterion A significantly interfere with academic achievement or activities of daily living. c. If a sensory deficit is present, the difficulties in the particular skill area (e.g., reading, writing, math) must be in excess of those usually associated with the deficit. LD Etiology Genetic predisposition Perinatal injury (e.g., complications during pregnancy) Neurological conditions (e.g., head injuries, serious falls, concussions, prolonged fevers, etc). Medical Conditions (e.g., lead poisoning, fetal alcohol syndrome, seizures, fragile X syndrome). Gathering Background Information 90% of a diagnosis is based on history. It is therefore imperative to gather specific information regarding the reported problem (e.g., did the problems occur early on, did the problems begin once the person began college). How does this apply to the Amendments Act that Dr. Brooks spoke about yesterday? Gathering Background Information (Continued) A thorough background interview is extremely important. Intake interviews that occur at Brigham Young University include the following areas: Presenting Concern (What is the client’s most pressing concerns?) Personal Background (e.g., previous testing, previous diagnosis, documentation of previous diagnosis, other languages spoken at home, current employment, marital status, struggles in school from k-12, held back a grade, easiest h.s. subjects, difficult h.s. subjects) Medical/Psychological Hx (pregnancy complications, developmental milestones, prolonged fevers, seizures, serious fall, concussions, serious physical illnesses, hospitalizations, current medical concerns, past emotional concerns, current emotional concerns, diagnosis of emotional concerns, current medications, previous substance abuse/use, toxic materials exposure) Family Hx (Number of brothers/sisters, which child, siblings diagnosed with LD/emotional concerns, parents diagnosed with LD/emotional concerns, parents educational background). Evaluations and Behavioral Observation A thorough evaluation will include a section dedicated to behavioral observations. Such behaviors that were observed either during testing or during the clinical interview are recorded in this area. These observations can give valuable information into the manner in which a client’s disabilities manifest themselves. There are some tests that help illuminate the amount of effort a client has put forth during LD testing (e.g., TOMM, Green’s Word Memory Test, CVLT, etc.) Discrepancy Model There are a number of statistical approaches that can be used to establish significant discrepancies (e.g., intra-individual achievement discrepancy, absolute achievement discrepancy, relative achievement discrepancy). The DSM-IV suggests that in order to be considered substantially below, a discrepancy of more than 2 standard deviations between achievement scores and IQ be present. Average Person Model The average person model asserts that a specific disability exists when a person has intellectual abilities that fall no lower than the Average range and achievement scores that fall below the Average range when compared to others of the same age. Furthermore, the identified disability significantly limits or restricts the condition, manner or duration under which an average person in the population can perform a major life activity (i.e. learning, listening). Reading Disorder DSM-IV Criteria: A. The essential feature of Reading Disorder is reading achievement (i.e., reading accuracy, speed, or comprehension as measured by individually administered standardized tests) that falls substantially below that expected given the individual’s chronological age, measured intelligence, and age appropriate education. B. The disturbance in Criterion A significantly interfere with academic achievement or activities of daily living that require reading skills. C. If a sensory deficit is present, the reading difficulties are in excess of those usually associated with it. From 60-80% of individuals diagnosed with Reading Disorder are males. However, the disorder occurs at more equal rates between males and females. Reading Disorders are often not fully apparent until the fourth grade or later. Reading disorders are more prevalent among first-degree biological relatives of individuals with Learning Disorders. Mathematics Disorder DSM-IV Criteria: A. Mathematic ability, as measured by individually administered standardized tests, is substantially below that expected given the individual’s chronological age, measured intelligence, and age appropriate education. B. The disturbance in Criterion A significantly interfere with academic achievement or activities of daily living that require mathematical ability. C. If a sensory deficit is present, the difficulties in mathematical abilities are in excess of those usually associated with it. Mathematics Disorder is commonly found in conjunction with Reading Disorder or Disorder of Written Expression. Approximately one in every five cases of Learning Disorders reveals a diagnosis of solely Mathematics Disorder. Mathematics Disorders are often not fully apparent until the fifth grade or later. Disorder of Written Expression DSM-IV Criteria: A. Writing skills, as measured by individually administered standardized tests (or functional assessments of writing skills), are substantially below that expected given the individual’s chronological age, measured intelligence, and age appropriate education. B. The disturbance in Criterion A significantly interferes with academic achievement or activities of daily living that require written texts (e.g., writing grammatically correct sentences and organized paragraphs). C. If a sensory deficit is present, the difficulties in writing skills are in excess of those usually associated with it. Disorder of Written Expression is rare when not associated with other Learning Disabilities. A disorder in spelling or handwriting alone, in the absence of other difficulties of written expression, generally does not qualify for a diagnosis of Disorder of Written Expression. Learning Disorder Not Otherwise Specified DSM-IV Criteria: This category is for disorders in learning that do not meet criteria for any specific Learning Disorder. This category might include problems in all three areas (reading, mathematics, written expression) that together significantly interfere in academic achievement even though performance on tests measuring each individual skill is not substantially below that expected given the person’s chronological age, measured intelligence, and ageappropriate education. LD NOS could be due to fluency or sub clinical problems across all of the aforementioned areas. Documentation - Achievement Woodcock Johnson III (WJ-III Tests of Achievement). Commonly used and widely accepted measure of achievement. Has 22 subtests that feed into Reading, Oral Language, Mathematics, Written Language, Academic Knowledge and Supplemental curricular areas. Using the Average Person Model, achievement scores below 90 indicate potential learning disabilities; provided that an individual’s IQ score is in the Average range. Broad Reading The Broad Reading cluster provides a comprehensive measure of reading achievement including reading decoding, reading speed and the ability to comprehend connected discourse while reading. Comprised of the following: 1. Basic Reading Skills 2. Reading Comprehension Broad Math The Broad Math cluster provides a comprehensive measure of math achievement including problem solving, number facility, automaticity and reasoning. Comprised of the following: 1. Math Reasoning 2. Math Calculation Skills Broad Written Language The Broad Written Language cluster provides a comprehensive measure of written language achievement including spelling of single-word responses, fluency of production, and quality of expression. Comprised of the following: 1. Basic Writing Skills 2. Reading Comprehension Other Achievement Tests Wechsler Individual Achievement Test (WIAT) Kaufman Test of Educational Achievement (KTEA-II) Wide Range Achievement Test (WRAT): Should only be used as a screening instrument. Nelson Denny Reading Test (ND): Should only be used as a screening instrument. If unsure about the validity of a particular achievement test, an excellent resource to help determine a test’s validity is the Mental Measurements Yearbook. It is also good practice to consult with colleagues concerning tests with which one is unfamiliar. Documentation – Intellectual Abilities Wechsler Adult Intelligence Scale III and IV (WAIS-III WAIS-IV). The WAIS-IV was just recently released. The WAIS-III and WAIS-IV are commonly used and widely accepted measures of intellectual abilities. Has 14 subtests, seven of which feed into a Verbal IQ (VIQ) and seven of which feed into a Performance IQ (PIQ). A composite or single Full Scale IQ is based on the combined scores of the Verbal IQ and the Performance IQ. Documentation – Intellectual Abilities In addition to the Verbal and Performance IQ’s are the following four indices and subtests used to create them: 1. Verbal Comprehension Index (VCI): a measure of verbal acquired knowledge and verbal reasoning (Vocabulary, Information, Similarities) 2. Perceptual Organization Index (POI): a measure of nonverbal, fluid reasoning, attentiveness to detail, and visual-motor integration. These scores are less dependent on quick responses than those of the Performance IQ (Picture Completion, Block Design, Matrix Reasoning) 3. Working Memory Index (WMI): a measure of one’s ability to attend to information, to hold briefly and process the information in memory, and then formulate a response (Arithmetic, Digit Span, Letter-Number Sequencing). 4. Processing Speed Index (PSI): a measure of one’s ability to process visual information quickly. This measure is more sensitive to neuropsychological conditions (Digit Symbol-Coding, Symbol Search) Other Intellectual Ability Tests Stanford-Binet Intelligence Scales (SB-5) Woodcock Johnson III –Tests of Cognitive Skills (WJ-Cog) Kaufman Assessment Battery for Children, Second Edition (KABC-II) Kaufman Brief Intelligence Test- Second Edition (KBIT-2): Should only be used as a screener. Slosson Intelligence Test-Revised (SIT): Should only be used as a screener. Wonderlic: Should only be used as a screener. There are also a number of culture-free/language free tests that should be interpreted with caution. Test of Nonverbal Intelligence- 3 (TONI-3) Documentation – Other areas for rule-outs Attention Deficit Hyperactivity Disorder (ADHD): There is a need to rule out this disorder as ADHD can affect working memory, fluency, etc. Some measures used to assess ADHD include: 1. Connor’s Continuous Performance Test-II (CPTII) 2. Integrated Visual and Auditory Continuous Performance Test Advanced Edition (IVA-AE) 3. Questionnaires (e.g., Hawthorne Self-Report, DSM Diagnostic Survey) Documentation – Other areas for rule-outs Socio-emotional functioning can also affect one’s working memory, fluency, etc. Some measures used to assess for emotional interference include: 1. Minnesota Multiphasic Personality Inventory-2 (MMPI-2) 2. The MMPI-2-RF has recently been released and is psychometrically up-to-date and linked to current models of psychopathology and personality. It has 338 items and reportedly takes just 25-35 minutes for computerized administration. 3. Millon Clinical Multiaxial Inventory-III (MCMI) 4. Personality Assessment Inventory (PAI) Prior Documentation Reasonable accomodations and services are based upon the current impact of the disability in the academic setting. Documentation should indicate that a specific disability does exist and that the documented disability limits or restricts the individual’s ability to perform major life activities (e.g., learning, listening). Documentation needs to be recent. Documentation also should be completed by a competent professional who is able to diagnose either learning/attention disabilities or emotional concerns. For Learning Disabilities documentation should be within the last 3-5 years. For student’s with IEP’s, it is wise to get updated testing that fulfills the criteria set forth by your college/university. For emotional concerns documentation should be updated on a yearly basis. Emotional concerns are not as stable as LD’s and can change within a year’s time. Documentation and IEP Individual Education Plans (IEP’s) should be used for guidance. If a student has an outdated IEP, use the IEP as a guide for provisional accomodations and have the student begin updated testing. Evaluating the Evaluation Many evaluators do not know disability law. Therefore, some of the recommendations made may not be supported legally (e.g., last week received a fax requesting that a student with OCD be allowed “at least three times the amount of time to complete testing”). If we do not carefully examine the recommendations set forth by some evaluators, we may actually inhibit a client’s potential for success (i.e., A student with OCD spending three to four times the amount of allotted time on a test may actually reinforce OCD behaviors). Collaboration It is good practice and necessary to obtain a signed release of information from the client before discussing his/her case with any other evaluator. Once a release of information is obtained, it is also good practice to speak with evaluators about clients and get answers to follow-up questions. The more consultation that occurs, the more likely we are to understand a client’s recorded disability and the more likely we are to provide appropriate and reasonable accommodations for the individual. Examples Good Documentation (Reports) Poor Documentation (Reports) Conclusion Discussion and questions.