What disorders are there with regard to language and learning? - Chapter 10

What is the historical perspective?

From around 1800 on, there has been attention on language-related problems. During this time, a medical orientation was developed, with specific limitations associated with brain abnormalities. For example, Wernicke discovered brain abnormalities in patients who did not understand language well, but who had no language or cognitive impairment – which you might know because there is a brain area named after him. From 1920 on, there was also a psychological orientation. During this period, more emphasis was placed on gaining insight into the characteristics of people with language and learning difficulties and treating them. In 1963, Krik introduced the term 'learning disabilities'. This is considered a milestone in the emergence of the concept of learning disabilities. For example, teachers were no longer accused of causing such problems.

Definition

According to the 'Individuals with Disabilities Education Act (IDEA)', the definition of a learning disability is as follows: “a learning disability is a disorder in one or more psychological processes involved in the understanding or use of (spoken or written) language. The disorder can affect listening, thinking, speaking, reading, writing, spelling or math. This does exclude children who have learning difficulties due to visual problems, hearing problems, a motor impairment, an intellectual disability, emotional problems or a cultural-economic disadvantage. There are no specific criteria for identifying disabilities. So there are different ways to identify learning disabilities. Differences in definitions have led to different prevalence estimates, incomparable research groups and different criteria for determining whether children are eligible for special education.

How do you go about identifying specific disorders?

Discrepancy between the IQ and performance level

There are two common ways to discover learning disabilities. First of all, we can look at the difference between someone's intellectual capacity (IQ) and specific performance level. It is assumed that if there is a specific disorder, the performance on general assets (IQ) is higher than the performance on tests that relate to the specific disability. Often a difference of two or more standard deviations between the scores on the intelligence test and the specific test is considered significant.

Below average performance

Another way to diagnose a disorder is to see if a child performs at least one academic area lower than the average classmate. A problem with this method is that a large discrepancy in younger children is more serious than in older children.

A below-average performance can also be identified by comparing the performance on a standardized test of a child with the performance of peers. A score is below average if the score is one or two standard deviations below average.

Both of the above methods have been criticized for the following reasons:

• The questions in intelligence testing are often strongly based on language skills, so the IQ of children with language or learning disabilities is often underestimated. This makes a discrepancy less likely.
• It is not possible to distinguish between shortages of the child and poor instruction.
• There are slow learners, for whom a discrepancy is not found.
• If there is a discrepancy with someone with a high IQ, the limitation can be very different from the limitation of someone with a discrepancy of a much lower IQ.

The first method is rarely used because of all these criticisms. Yet the intelligence is still taken into account, because a requirement is that the child with a low performance must have an IQ higher than 70. Children with both a low performance level and a low IQ are therefore not considered to be individuals with a learning disability (simply just not that smart overall).

Response to intervention

A new approach is the response to intervention (herafter RTI). Children are exposed to a program before they are possibly diagnosed with a disorder. The assumption underlying this approach is that children who respond poorly to peers in this program can be diagnosed with a learning disability. With the RTI method, children are exposed to interventions with increasing intensity. A group of children receives a specific intervention and the progress of each child is monitored. Children with deficits then receive a more intensive program and a new evaluation follows. The children who still did not respond well to the intervention are subsequently diagnosed with a learning disability. Researchers are divided on the RTI method. For example, some have doubts about involving all students in the process. They fear that this will lead to a shift from the conceptualization of learning disabilities as a specific limitation to a more general limitation of low performance, which may prevent some students from receiving the special attention they need.

What are the language disorders?

The term aphasia used to be used to refer to language disorders. This term literally means language loss due to brain injury or brain dysfunction. When it comes to young people, aphasia is not a suitable term and the term developmental dysphasia was used. This terms has led to the emergence of terms such as language impairment , specific language impairment and specific language impairment .

Normal development

An overview of normal language development is used as the framework for understanding language limitations. Language comprises a number of basic components:

• Phonology: the sounds (phonemes) of a language and the rules for combining these sounds. The letters of the alphabet are called grapheme.
• Morphology: the creation of words, including the use of front and back seals to give meaning to them.
• Syntax: the organization of words in sentences.
• Grammar: the system of rules that organize a language. Morphology and syntax are parts of grammar.
• Semantics: the language rules that have to do with the meaning of words and sentences.
• Pragmatics: the use of language in specific contexts. For example, you know that in a conversation it is normal that you do not constantly talk yourself but give the other person time to respond.

In addition to these basic components, a distinction can be made between receptive and expressive language. When we use receptive language, we mean the understanding of messages from others. Expressive language stands for the production of language and the sending of messages. Receptive language develops quiker than expressive language.

In the first year of life, babies can distinguish between sounds of all languages. Subsequently, this ability is limited to the sounds of the mother tongue. So it seems that the innate capacity to process language sounds is formed through experience. Around the age of 1, most babies can say a few words. Around the age of 2, most children are able to say longer sentences. The vocabulary increases considerably and the ability to put words in the right order increases. The receptive language is also developing further. Around the age of 7, children have acquired the most basic language skills. Yet language development continues into adolescence and even into adulthood.

DSM classification

Problems can occur in all sorts of parts of language. Subgroups of language disorders are difficult to make, but a distinction is often made between people who have problems with receptive language and people who have difficulty with expressive language. The DSM distinguishes within the Communication disorders category, with these two categories as wel. The speech sound disorder (phonological disorder) and the language disorder are the most important disorders within this (expressive) category.

Phonological disorder

A child with a phonological disorder is unable to make age-appropriate and dialect-appropriate speech sounds. Children with this disorder have problems articulating speech sounds. The development of speech production does not deviate from normal development, but it is delayed. Children with a phonological disorder make incorrect speech sounds, replace easy sounds with difficult sounds or just omit sounds all together. Because most children have some difficulty with articulation while acquiring the linguistic and motor skills required for language, developmental standards are crucial to this diagnosis.

In phonological disorder, there is not only always an inability to produce speech accurately, but there may also be a more general problem in understanding the sound structure of language.

Language disorder

The primary problems of a language disorder are the limitations of obtaining or using language because of limitations in understanding or producing language.

The expressive problems concern the production of language with regard to vocabulary, grammar and other aspects of language output. Children with expressive problems have limited vocabulary and speak in short, easy sentences. Often important parts of sentences are missing, and the sentence structure is incorrect. The distinction between verbs and nouns is not expressed in the production of language. There may also be phonological problems. Children with expressive problems do, however, understand language well.

Receptive problems

When a child has Receptive problems, there are problems with understanding other people's communication. A child with this disorder does not respond to speech, appears deaf, responds incorrectly or is not interested in television or other audible media (music excluded).

Epidemiology and development process

The prevalence estimates of language disorders range from 3-7%. The prevalence varies with age and the type of disorders. In addition, the prevalence is higher for boys than for girls. Children with a low socio-economic status also suffer more often from a language disorder.

Language disorders often manifest themselves around the third or fourth year of life, but a child with mild problems can also become apparent later than that. Some disorders only properly manifest when children go to school. Over time, language skills can improve, and complete recovery is even possible. Children with only articulation problems have the least risk of permanent problems and children with expressive disorder have a moderate risk of permanent problems. Children with a receptive-expressive disorder run the greatest risk of later language disorders. They almost always keep linguistic deviations as they get older. Sometimes their problems worsen over time. In general it can be said that if problems have not improved around the age of 5 or 6, children run a risk of permanent language and reading problems. Even when the problems diminish, there is a chance that reading problems will arise later in life.

Comorbidity

Language disorders are often associated with poor academic progress and learning disabilities. For example, children with language disorders have reading problems much more often. Young people with both a language and learning disability have a higher risk of other disorders. Language limitations are associated with externalizing and internalizing problems Children who only have articulation problems have the least and least severe psychological problems.

Cognitive deficits

Children with a language disorder often have non-linguistic cognitive deficits, such as in the speed of information processing, auditory perception and memory. A hypothesis states that there is a general limitation in information processing capacity in children with a language disorder. The information processing model states that children with a language disorder are limited in the speed of their information processing. They respond more slowly to tasks. A problem with this hypothesis, however, is that children with general learning difficulties also experience slow information processing.

A more specific hypothesis establishes a link between language disorders and deficiencies in auditory processing. Research shows that children with a language disorder have difficulty identifying fast sounds in speech. In addition, babies with a risk of language and learning disabilities (because it occurs in the family) need more time to process auditory stimuli. All in all, however, the research findings are inconsistent. It can be concluded that auditory weathering makes a weak contribution to language disorders at most.

A third hypothesis states that deficits in verbal short-term memory and verbal working memory play a role in language disorders. The verbal short-term memory temporarily stores linguistic information and is involved in the phonology of language. Children with language disorders tend to have deficits when it comes to this. This is evident, among other things, from the fact that they have difficulty repeating non-existent words immediately. The verbal working memory is involved in both storing and processing of verbal information. With this, it is necessary to keep verbal information 'online' while it is being processed, such as when following a number of instructions. Children with language disorders have trouble doing this. Such problems, however, are not at the root of language problems, they are not what causes them, but they do probably contribute to the reading and calculation problems associated with it.

What do we mean with learning disabilities?

Learning disabilities refer to specific reading, writing, and math problems. These disorders are known under the denominator of dyslexia, dysgraphia and dyscalculia respectively. Shortages often occur in combinations. For example, a reading disorder is often accompanied by a calculation disorder.

DSM classification

The DSM-IV calls these reading disorders: Specific Learning Disorders. This is defined as difficulties in learning and using academic skills for a period spanning longer than at least 6 months. The following difficulties can arise reading words, understanding, spelling, written expression, number understanding and mathematical reasoning. These are divided into 3 domains: reading disorder, writing disorder and arithmetic disorder. A child is diagnosed with one or more of these disorders if he or she scores significantly lower on a standardized reading, writing or arithmetic test given his or her age, intelligence and education. In addition, the problems must significantly interfere with academic performance or with daily activities, for which the skill is required. Finally, the problems cannot be explained by a sensory deficit, such as hearing problems.

Reading disorders

Reading can be defined as the process whereby meaning is given to written text. Children with reading disorders have difficulty recognizing written words and / or correctly pronouncing words when reading aloud. They can also have a slow reading pace, limited vocabulary and limited text comprehension. There are no subtypes of reading disorders. A distinction can be made between problems with reading words and problems with understanding written text.

Problems reading words

The term dyslexia refers to difficulty in reading words or acquiring reading skills. Phonological processing plays an important role in this: using the sound structure of language to process written text. Before children can learn to read, they need to be aware that speaking can be divided into sounds. This is also called phonological awareness . For example, children must learn that the word "book" consists of three sounds. For learning to read, it is also important that children understand that letters (graphemes) correspond to sounds (phonemes) and that they can link letters and sounds to each other.

Problems with understanding text

Some children can read text accurately but are unable to understand its content. Deficiencies in vocabulary and grammar play a role in this. At a later age, the metacognitive capacity is also involved in text comprehension. If a child has this ability (metacognitive capacity), they are able to draw conclusions about the purpose of the text, to assess their own text comprehension and to revise their own text comprehension if necessary.

Reading problems often arise around the age of 9. Research shows that children with reading difficulties at this age may have gone through one of the following three paths: (1) a path with consistent poor reading, (2) a path with fluctuating reading performance and (3) a path with a dramatic relapse. There are two possible explanations for the latter path: (1) children have not acquired the early phonological processing skills but have camouflaged this by means of "sight reading" (memorizing what certain words look like), or (2) children inadequately processed phonological processing skills, which becomes visible as reading tasks become more complex.

Epidemiology

The prevalence estimates of reading disorders range from 4-10%. Boys tend to have a reading disorder more often than girls. This is possibly explained by genetic influence and a selection bias. In some countries there are more people who suffer from reading disorders. This may have to do with different language structures, differences in social attitudes towards reading problems or methodological factors.

Development process

Reading disorders often persist until adolescence and adulthood. However, there is variation in the outcomes. Some children who have poor reading skills at a young age do not suffer from this in adolescence anymore. With other children, reading problems remain stable or worsen. The Mathew Effect refers to the widening of the gap between strong and weak readers. The social class and behavioural problems are two of the strongest predictors of the outcomes of a reading disorder.

Comorbidity

Reading disorders are associated with language and other learning disabilities. In addition, it is often accompanied by behavioural disorders, especially among boys. Finally, there is a connection between reading disorders and ADHD. Reading problems are more related to the carelessness of ADHD than to hyperactivity-impulsivity.

Writing disorders

Children with writing disorders have a slow writing pace, make a lot of writing errors, have poor handwriting and find it difficult to clearly organize the content. Transcription refers to the verbalization of ideas. This is fundamental to the early development of writing. The central problems with poor transcription are poor handwriting and spelling errors. A good handwriting not only requires motor skills, but also that letters are stored and retrieved from memory. Good spelling skills depend on, among other things, understanding the connection between sounds and spelling, word recognition and retrieving learned words from memory. Children who suffer from this is issue tend to mix up specific letters or sounds that they have troubles differentiating between.

Text generation (composition) refers to the creation of meaning in written form. In order to be able to do this, the child must be able to retrieve words, sentence structure and stored information about the subject from the memory. Higher executive functions and metacognitive skills are also important. Children with writing difficulties find it difficult to make a plan, to organize points, to connect ideas to each other and to write in a goal-oriented way.

Epidemiology and development process

About 6 to 10% of the children have a writing disorder. There are not very many standardized writing tests, so diagnoses are often made based on analysis of paperwork. Development standards are important when assessing the quality of work. A writing disorder often becomes visible around 2nd grade and referral increases around 4th grade when writing at school increases and becomes more complex. There is a lack of longitudinal research into the developmental development of writing disorders, but cross-sectional research suggests that the disorder continues to exist in some young people.

Calculation disorders

The term calculation disorder refers to problems with the basic calculation skills. Children with a math disorder have difficulty adding and subtracting, understanding mathematical symbols and terms, remembering sums and understanding spatial organization. The primary problems are understanding numbers and learning, representing and retrieving basic sums.

It seems that babies and some animals have primitive numerical skills. For example, babies of 6 months can distinguish between a group of 8 dots and a group of 16 dots, but not between a group of 16 and a group of 24 dots. Such findings indicate that before language acquisition, people have a representation of magnitude on which numeracy skills are based.

Around the age of 5, children understand the basic principles of counting. A gradual shift is taking place from simple calculations to more advanced procedures. Initially everything is counted (counting all; 2 + 3 is calculated by counting 1-2-3-4-5), but later this makes way for further counting ( counting on; the child starts at 2 and adds 3 to this) ). The latter strategy is more convenient, because the answer to a sum is then found more quickly. Subsequently, counting procedures are represented in the memory and calculations can be retrieved automatically from the memory. It is therefore no longer necessary to count as 2 + 3 for a sum, because the answer is retrieved from the memory quickly and without much effort.

Children with calculation problems learn calculation strategies relatively slowly. In addition, they use strategies less often, less accurately and at a slower pace. They also have difficulty retrieving maths from memory.

Longitudinal examinations are needed to study the developmental course of calculating disorders. In addition, some researchers have not made a distinction between children with only math problems and children with both math and reading problems. Thirdly, research is needed to identify the underlying cognitive deficits that are involved in calculation problems, such as working memory and visual-spatial skills. Finally, it should be noted that evidence has been found for genetic influence, but the acquisition of math skills also depends on the quality of instruction in the classroom.

Epidemiology and development process

About 5 to 8% of the children have a math disorder. No gender difference was found in most studies. Little research has been done so far into the development of calculating disorders. However, it appears that these disorders are persistent.

What are the secondary problems?

Social relationships and competences

Some children with language and learning disabilities have social problems. They are often not popular and are rejected or ignored by peers. They have fewer friends and worse friendships and experience more feelings of loneliness. These social problems may be partly explained by the link between learning disabilities and behavioural problems, such as ADHD. In addition, children with learning disabilities have a lower social competence. They can have problems identifying the emotional expression of others, understanding social situations, empathy and solving social problems.

Academic self-image and motivation

Learning disabilities are associated with low self-esteem and a negative academic self-image, which in turn is related to motivation problems. Children with a learning disability can therefore end up in a vicious circle: they achieve poor school performance, which makes them feel that they have no control over the situation. They think that efforts are useless and give up. As a result, school performance remains poor, which means that children increasingly have the idea that they cannot do it, and so on.

Brain disorders

Language and learning difficulties are associated with cerebral palsy, epilepsy, nervous system infections, head injury, prenatal alcohol use, premature birth, low birth weight and neurological deficits. In particular, much research has been done into the role of the left hemisphere in language and learning disabilities, as it is considered crucial for language functions.

Brain structure

We looked at structures of the brain, in particular the structure of the temporal planum and the surrounding area. This area corresponds to the area of ​​Wernicke and is used in language. It contains the upper part of the temporal lobes and extends to the lower part of the parietal lobes. For many adults, this area is larger in the left hemisphere than in the right hemisphere. For people with a language or reading disorder, this is not the case and the area in the right hemisphere is the same size or larger than in the left hemisphere. The left temporal lobes are also smaller than normal. People with a language or learning disability also often have cell abnormalities in the brain. However, a number of limitations must be taken into account when interpreting the research findings. The research findings may not be generalizable to children. In addition, the samples are often small, and the results are inconsistent.

Brain functions

Much attention has been paid to studying brain activity while people perform language and reading tasks . Differences have been demonstrated between readers with and without a disorder of brain parts involved in language and reading:

• Broca's area: an area at the front of the brain that helps with the analysis of words.
• The parietal-temporal area (includes the Wernicke area) plays a central role in phonological processing.
• The area at the intersection of the occipital and temporal lobes is involved in rapid and automatic word recognition.

Strong readers use the posterior parts of the brain relatively more for reading and most of the processing takes place in the left hemisphere.

It has been stated that reading disorders are caused by incorrect connections in the system that are required for language and reading skills. Studies show that patterns of brain activity are different in children and adults with and without reading problems. For example, in people with reading problems, the rear left part of the brain is not sufficiently active, and the right part is too active. The frontal left part of the brain can also be too active. Children with reading problems use the frontal part of the brain more and more as they get older. Shaywitz suggests that some weak readers can read accurately by using alternative routes (more use of the anterior brain area and right hemisphere), although they still have difficulty reading fluently and fluently.

What is the aetiology?

Genetic influences

Evidence has been found of the influence of genetic factors and heredity on language, reading, writing and math problems. The fact that different language and learning limitations are often accompanied is partly explained by a shared genetic influence.

Psychosocial influences

Different psychosocial variables are important in normal language development . The growth of vocabulary is, for example, due to the number of words the child hears from the mother. Language development is faster when a mother responds to her child's speech and makes comments about what the child pays attention to. Although family factors are not the cause of language problems, they can maintain them. Large families and aspects of mother-child interaction are related to reading problems. Factors such as the size of the class, fear of calculation and the quality of lessons can also influence the acquisition of math skills.

Assessment

In the assessment of language and learning difficulties, attention must be paid to various aspects:

1. the development of the child
2. speech and language skills
3. verbal and non-verbal intelligence
4. hearing, neurological characteristics and medical history.

Standardized tests to assess language, reading, writing and math skills are crucial in the assessment. If relevant, attention can also be paid to the child's learning habits, motivation and self-esteem.

How do you treat and / or intervene?

Prevention

The prevention of developmental disorders lies in the early identification and treatment of problems. With regard to language limitations, it can be difficult to identify problems at a young age. The response to intervention approach is seen by some as a way to prevent reading problems. The exposure of children to an intervention (curriculum) is considered as primary (universal) prevention. Students who perform less well than their classmates receive a more intense intervention, which is considered a secondary (selective) prevention. Those who also respond poorly to this intervention are assessed to see if they are eligible for special education, which can be considered as tertiary (indicated) prevention. Response to intervention therefore integrates prevention with treatment.

Interventions for language disorders

Language development can be improved, although this depends on the seriousness of the problems and on the methods used to improve language development. Articulation and expressive skills are easier to improve than receptive skills. Treatments often use operant procedures. Although language skills often improve, many children do not reach the level of their peers, so that academic and social problems persist. Moreover, there is little evidence for the effectiveness of treatments for receptive problems.

Interventions for learning disabilities

In the 60s and 70s, interventions were based on three approaches:

1. Medical model: states that learning problems arise from biological causes, such as neurological deficits. However, there is little evidence for this model and the associated treatment methods.
2. Psycho-educational model: states that certain perceptual and cognitive processes underlie learning difficulties. Examples of treatments based on this approach are the practice of eye-hand coordination, spatial relationships or language. However, there is little evidence for the effectiveness of such treatments.
3. Behavioural model: has no assumptions about the causes of learning difficulties but focuses on improving social and academic skills through learning principles, such as feedback and modelling.

These three approaches have contributed to the way learning problems are treated today.

Research shows that the following approaches are effective in handling reading, calculation and writing problems:

• Direct instruction (task-analytical): includes formulating goals, offering new material in small steps with clear and detailed explanation, guiding students and assessing the student's progress.
• Cognitive approach: tries to make the child aware of what is needed in the learning task, which learning strategies should be used and how strategies should be varied.
• Cognitive behavioural approach: states that children must lead their own learning processes. They must keep track of what they learn, assess their progress, reinforce their own behaviour, and regulate their learning behaviour in other ways.

Special education

The 'Individuals with Disabilities Education Act' (IDEA) has four goals:

1. All pupils with disabilities receive appropriate public education that meets their specific needs.
2. The rights of students with disabilities and their parents are protected.
3. States and local institutions are supported in providing education to students with disabilities.
4. Assessing and guaranteeing the effectiveness of education.

Appropriate education actually means that education is adapted to the needs of each individual child. An individual education plan (IEP) is drawn up for each child with special needs by a team of professionals and the parents of the student. An IEP specifies the current functioning of the child, annual educational goals, the moments and ways in which progress is assessed, the services offered and (for older pupils) the goals and services for the transition from primary education to secondary education

The IDEA states that children with a disability should be placed in the least restrictive environment. This means that they should be placed as much as possible in classes with children who have no disability. This is also called mainstreaming . In addition, the principle of inclusion states that schools must meet the needs of all students. Proponents of inclusion argue that inclusion is beneficial for both the learner and his or her classmates in terms of social and academic outcomes. Critics, on the other hand, argue that there is little evidence of a positive effect of inclusion on academic outcomes and that it leads to a lower self-esteem of the student with the disability. In general, research offers more support for inclusion. However, inclusion requires that the special educational needs of the pupil with the disability be met.

In practice, pupils with special educational needs have different options, ranging from regular education with or without supervision, to special classes in regular education, to special education in an outpatient or residential setting. Most pupils with a disability follow regular education with varying levels of extra supervision.