SEMINARS I N NEUROLO(;Y-VOLUME
11, N O . 1 MARCH 1991
Educational Assessment and Remediation of Learning Disabilities
Educational assessment involves the administration of educational tests in such areas as reading, spelling, written language, and mathematics, as well as the evaluation of the test results. T h e goals of educational testing are to determine the approximate achievement level of a student in particular subject areas and to provide diagnostic information. This information is often used to determine if a child is in need of remedial help and whether or not the child qualifies for special services in school. It is also used to set u p an effective remedial program for the child. Educational assessment is a science and an art of which psychologic assessment is a complementary partner. T h e clinician must be competent in the selection of appropriate tests and in the correct administration of those tests, as well as the accurate interpretation of the test results. T h e competent evaluator does not rely solely on test results; he must be a keen observer and perceptive interviewer. An understanding of what the child brings to the testing situation is critical; this involves interpreting information from the home, school, and physician. In a thorough evaluation, a child's difficulty with poor abstract reasoning ability, shortterm auditory memory, o r visual-motor integration would usually manifest itself on both the psychologic and educational assessments. Often a speech and language evaluation is needed to complete a differential diagnosis. In order to be identified as having a learning disability (LD), a child must exhibit a severe discrepancy between his potential, as indicated by the intellectual assessment, and his achievement, as indicated by the educational assessment. Each state
has established its own criteria for determining whether a child qualifies for services as LD. Achievement tests must be given in the following seven areas: basic reading skill, reading comprehension, mathematics calculation, mathematics reasoning, written expression, oral expression, and listening comprehension. All of these areas except oral expression and listening comprehension will be addressed in this article. This article discusses test selection and the interpretation of test results, including the effect attentional factors may have on test results. Dyslexia is discussed with an emphasis on how to diagnose this disorder. T h e underidentification of LD and/or attention deficit hyperactivity disorder (ADHD) in girls and gifted children is addressed. T h e characteristics of the nonverbal learning disability (NLD) syndrome are discussed. Finally, general guidelines for remediation and conclusions are presented.
TEST SELECTION In selecting achievement tests, individual achievement batteries are often used. These batteries are particularly appropriate because they are usually untimed and because the need for reading instructions is reduced o r possibly eliminated. Achievement tests are typically not diagnostic; they strictly assess performance levels in the various areas. T h e Kaufman Test of Educational Achievement (K-TEA)' is an individual achievement test
Co-Director, Learning Assessment Clinic, 'The UME 1 I . N U M B E R 1 MARCH 1991
deficits of children with reading disability and ADHD, two disorders that frequently coexist. They determined that the cognitive deficits are different for each of these disorders and that these differences manifest themselves as early as first grade. ADHD affects the memory domain, and the effects are more variable over time as children learn coping mechanisms. During the educational evaluation, ADHD children typically exhibit difficulties in mathematical computation and in the organizational and mechanical aspects of written expression, including handwriting, capitalization, and punctuation. Proofreading skills are often nonexistent. Attention difficulties can also negatively affect reading comprehension. These difficulties may show up more readily on a test requiring sustained reading and self-pacing, a test such as the SDRT, than on an individually administered test such as the K-TEA which involves shorter passages and interaction with the evaluator.
DYSLEXIA In the past 10 to 15 years, researchers in the fields of neurology, psychology, education, and linguistics have made significant process in understanding the true nature of dyslexia. The word "dyslexia," which means difficulty (dys) with words (lexicos), is an appropriate term, since it is believed that dyslexia is a language-based disorder that results in an impairment in the brain's ability to process written symbols and causes otherwise healthy, bright youngsters to have significant difficulty learning to read and spell. T h e etiology of dyslexia is still unknown, but it is four times more frequent in boys than in girls. An estimated 10 to 15%of the population has this disorder, which may range from mild to severe.lx Because dyslexia is a language-based disorder, its early signs are manifested in the language development of the child and may include delay in spoken language, difficulty "finding" the right word, difficulty with rhyming, difficulty with short-term auditory memory, subtle mispronunciations, particularly of longer words (for example, aminal for animal), and confusion of time concepts such as before and after, yesterday and tomorrow. As the child grows older and enters school, these language-based problems are manifested as reading and spelling difficulties. The following problems may emerge: difficulty learning the names of the letters of the alphabet, difficulty learning to write the alphabet, difficulty learning whole words for reading and spelling, difficulty
learning and using phonics for reading and spelling, and difficulty with reading comprehension, often related to inability to decipher words. Extensive research has eliminated visual processing deficits as the root of the problem." Dyslexics do not "see words backwards." Visual training and tinted lenses therefore have not proved to be effective in the remediation of reading and spelling problems. It is important to remember that not all dyslexic people exhibit reversals and not all people who exhibit reversals are dyslexic. Incorrect sequencing of letters such as reading or spelling "felt" for "left" can indicate poor phonetic analysis skills rather than a visual processing problem. Research does not support a significant relationship between early visual-spatial problems and reading problems, although a small percentage of dyslexics do appear to have visual-spatial deficits." DIAGNOSING DYSLEXIA
Although the term "dyslexia" is used synonymously with the term "specific reading disability," dyslexia is far more than a reading problem. Because dyslexia is a language-based problem, the clinician must be sensitive to the spoken language problems often present with this disorder, including subtle mispronunciation of words, particularly multisyllable words, and word retrieval difficulties. A thorough family history of learning difficulties should be taken in order to establish whether or not there is a family history of speech, reading, and written language difficulties. The reading assessment must include a thorough evaluation of a child's decoding ability, oral reading fluency, and phonologic ability. Because poor and sometimes bizarre spelling is characteristic of dyslexia, spelling must be carefully analyzed as well as handwriting and written language skills. The decoding process involves the conversion of print into auditory equivalents or sounds. It begins with the conversion of individual letters into sounds and progresses to syllables, words, phrases, and sentences. Decoding is a prerequisite skill for reading comprehension because if one cannot decipher the words, one cannot comprehend the text.' The following questions must be answered in assessing decoding skills. Does the child have an adequate sight vocabulary to allow for fluent reading of text? This can readily be assessed by word recognition subtests on tests such as the K-TEA and WJPB. The second question is more difficult to answer. How well does the child use word analysis skills, including phonetic analysis and structural analysis skills, to unlock unfamiliar words?
Downloaded by: University of Pennsylvania Libraries. Copyrighted material.
ASSKSSMEN'I' A N D RE:ME:I)IKI'ION O F 1,E:AKNING DISABII~I7'IES-DAKIN
46
The clinician should have an in-depth knowledge of word analysis skills in order to assess them accurately. (Lernerlg includes a short phonics quiz to assess the teacher's knowledge of phonics and a brief review of phonics generalizations in her excellent textbook on learning disabilities.) Does the child know the sounds associated with the letters of the alphabet as well as the consonant and vowel combinations? If the child has a firm understanding of these sound-symbol relationships, does he apply this knowledge when he is reading? Does the application of this knowledge break down when the child encounters two or more syllable words? Does the child accurately read common prefixes and suffixes? The following tests are helpful when assessing word analysis skills. T h e Word Attack subtest on the WJPB and WJPB-R uses nonsense words to assess a child's word analysis skills because the child cannot recognize the words as sight words and therefore has to rely on his word analysis skills to decode the words. T h e Decoding Skills Test (DST)"' is a diagnostic, criterion-referenced instrument that assesses a child's ability to use word analysis to read unknown words. It compares word analysis skills and word recognition skills using words in isolation versus contextual material. An assessment of oral reading fluency is also included as part of this test. It is important to include an assessment of oral reading fluency as part of a complete reading evaluation because the dyslexic reader usually exhibits dysfluent oral reading and requires specific remediation to improve this skill. Finally, the DST also includes a measure of comprehension. The DST can be used with readers on the first to fifth grade levels. Extensive research supports the relationship between phonologic processing difficulties and reading difficulties."-I" Because of this relationship, I recommend including an assessment of phonologic skills as a component of a complete reading assessment. Sparks et al" suggest that phonologic, syntactic, andlor semantic processing deficits can interfere with the acquisition of foreign language skills at the college level. They suggest using the Goldman-Fristoe-Woodcock Auditory Selective Attention Test2' and the Goldman-FristoeWoodcock Sound-Symbol Tests, subtests 1,4,6,7,23 for probing phonologic problems involving auditory discrimination of sound elements, auditory blending of sound elements, memory for sound elements, and auditory distractability. In addition, I suggest using the Blending subtest of the WJPB, the Sound Blending subtest of the WJPB-R, and the Lindamood Auditory Conceptualization Test'" as possible diagnostic tests for assessing phonologic abilities.
V 0 1 , U M E I I , N U M B E K 1 ILZARCH 1901
The dyslexic child's decoding skills are usually poorer than his reading comprehension skills. He is able to compensate somewhat for poor decoding skills by using context, but inevitably comprehension is compromised by lack of automaticity. If the dyslexic child also has attentional problems, it is difficult for him to exert the attention needed to make good use of context and therefore he is less likely to be able to compensate for his poor decoding skills. An assessment of handwriting is important because many dyslexic children have significant handwriting problems. Initially, they often have difficulty recalling how to form the manuscript letters and may confuse letters that are similar except for their position in space, such as b,d,p, and cl. They may also use an atypical grip and have difficulty with proper spacing, the letter-size relationship, and the spatial organization of the page. l'he transition to cursive handwriting is typically not made smoothly and usually requires extra help and effort. Often the child reverts back to printing because the transition is not completed. Cursive handwriting should be encouraged because it flows and therefore, once mastered, should be more efficient. Cursive handwriting is likely to decrease the possibility of reversal errors. It is interesting to note that dyslexic children may have difficulty with handwriting, but may be very talented artists and very creative with their use of three dimensional forms such as building toys and blocks. Dyslexic children usually have significant difficulty with spelling and therefore spelling should be carefully evaluated. The Boder Test of ReadingSpelling Patterns'Qategorizes spelling errors into the following types: spelling errors of the auditorvphonetic (dysphonetic) type, visual-spatial (dyseidetic) type, or the most severe, the mixed type, involving errors of both types. Researchers have challenged the distinction between linguistic and visuo-spatial types of spelling errors and have found that types complicated by the presence of ADHD were unstable over time.lPThe Test of Written Spelling-2 ('I'WS-2)"' assesses a child's ability to spell predictable words, words governed by spelling rules, and unpredictable words or irregular words. The TWS-2 appears to have adequate reliability and validity,' but often is not a particularly helpful diagnostic instrument because the categorization of a number of included words as either predictable or unpredictable is questionable. These two tests are not recommended because they may not produce meaningful diagnostic information. A skilled clinician should be able to determine the kinds of spelling errors a child makes from an informal assessment of a child's spelling by carrying out an error analysis of his spelling errors both
Downloaded by: University of Pennsylvania Libraries. Copyrighted material.
S E M I N A K S I N NEUKOI,O(;Y
ASSESSMEN?' A N D KEMEDIA71'ION OF I.EAKNIN
11, N O . 1 MARCH 1991
Educational Assessment and Remediation of Learning Disabilities
Educational assessment involves the administration of educational tests in such areas as reading, spelling, written language, and mathematics, as well as the evaluation of the test results. T h e goals of educational testing are to determine the approximate achievement level of a student in particular subject areas and to provide diagnostic information. This information is often used to determine if a child is in need of remedial help and whether or not the child qualifies for special services in school. It is also used to set u p an effective remedial program for the child. Educational assessment is a science and an art of which psychologic assessment is a complementary partner. T h e clinician must be competent in the selection of appropriate tests and in the correct administration of those tests, as well as the accurate interpretation of the test results. T h e competent evaluator does not rely solely on test results; he must be a keen observer and perceptive interviewer. An understanding of what the child brings to the testing situation is critical; this involves interpreting information from the home, school, and physician. In a thorough evaluation, a child's difficulty with poor abstract reasoning ability, shortterm auditory memory, o r visual-motor integration would usually manifest itself on both the psychologic and educational assessments. Often a speech and language evaluation is needed to complete a differential diagnosis. In order to be identified as having a learning disability (LD), a child must exhibit a severe discrepancy between his potential, as indicated by the intellectual assessment, and his achievement, as indicated by the educational assessment. Each state
has established its own criteria for determining whether a child qualifies for services as LD. Achievement tests must be given in the following seven areas: basic reading skill, reading comprehension, mathematics calculation, mathematics reasoning, written expression, oral expression, and listening comprehension. All of these areas except oral expression and listening comprehension will be addressed in this article. This article discusses test selection and the interpretation of test results, including the effect attentional factors may have on test results. Dyslexia is discussed with an emphasis on how to diagnose this disorder. T h e underidentification of LD and/or attention deficit hyperactivity disorder (ADHD) in girls and gifted children is addressed. T h e characteristics of the nonverbal learning disability (NLD) syndrome are discussed. Finally, general guidelines for remediation and conclusions are presented.
TEST SELECTION In selecting achievement tests, individual achievement batteries are often used. These batteries are particularly appropriate because they are usually untimed and because the need for reading instructions is reduced o r possibly eliminated. Achievement tests are typically not diagnostic; they strictly assess performance levels in the various areas. T h e Kaufman Test of Educational Achievement (K-TEA)' is an individual achievement test
Co-Director, Learning Assessment Clinic, 'The UME 1 I . N U M B E R 1 MARCH 1991
deficits of children with reading disability and ADHD, two disorders that frequently coexist. They determined that the cognitive deficits are different for each of these disorders and that these differences manifest themselves as early as first grade. ADHD affects the memory domain, and the effects are more variable over time as children learn coping mechanisms. During the educational evaluation, ADHD children typically exhibit difficulties in mathematical computation and in the organizational and mechanical aspects of written expression, including handwriting, capitalization, and punctuation. Proofreading skills are often nonexistent. Attention difficulties can also negatively affect reading comprehension. These difficulties may show up more readily on a test requiring sustained reading and self-pacing, a test such as the SDRT, than on an individually administered test such as the K-TEA which involves shorter passages and interaction with the evaluator.
DYSLEXIA In the past 10 to 15 years, researchers in the fields of neurology, psychology, education, and linguistics have made significant process in understanding the true nature of dyslexia. The word "dyslexia," which means difficulty (dys) with words (lexicos), is an appropriate term, since it is believed that dyslexia is a language-based disorder that results in an impairment in the brain's ability to process written symbols and causes otherwise healthy, bright youngsters to have significant difficulty learning to read and spell. T h e etiology of dyslexia is still unknown, but it is four times more frequent in boys than in girls. An estimated 10 to 15%of the population has this disorder, which may range from mild to severe.lx Because dyslexia is a language-based disorder, its early signs are manifested in the language development of the child and may include delay in spoken language, difficulty "finding" the right word, difficulty with rhyming, difficulty with short-term auditory memory, subtle mispronunciations, particularly of longer words (for example, aminal for animal), and confusion of time concepts such as before and after, yesterday and tomorrow. As the child grows older and enters school, these language-based problems are manifested as reading and spelling difficulties. The following problems may emerge: difficulty learning the names of the letters of the alphabet, difficulty learning to write the alphabet, difficulty learning whole words for reading and spelling, difficulty
learning and using phonics for reading and spelling, and difficulty with reading comprehension, often related to inability to decipher words. Extensive research has eliminated visual processing deficits as the root of the problem." Dyslexics do not "see words backwards." Visual training and tinted lenses therefore have not proved to be effective in the remediation of reading and spelling problems. It is important to remember that not all dyslexic people exhibit reversals and not all people who exhibit reversals are dyslexic. Incorrect sequencing of letters such as reading or spelling "felt" for "left" can indicate poor phonetic analysis skills rather than a visual processing problem. Research does not support a significant relationship between early visual-spatial problems and reading problems, although a small percentage of dyslexics do appear to have visual-spatial deficits." DIAGNOSING DYSLEXIA
Although the term "dyslexia" is used synonymously with the term "specific reading disability," dyslexia is far more than a reading problem. Because dyslexia is a language-based problem, the clinician must be sensitive to the spoken language problems often present with this disorder, including subtle mispronunciation of words, particularly multisyllable words, and word retrieval difficulties. A thorough family history of learning difficulties should be taken in order to establish whether or not there is a family history of speech, reading, and written language difficulties. The reading assessment must include a thorough evaluation of a child's decoding ability, oral reading fluency, and phonologic ability. Because poor and sometimes bizarre spelling is characteristic of dyslexia, spelling must be carefully analyzed as well as handwriting and written language skills. The decoding process involves the conversion of print into auditory equivalents or sounds. It begins with the conversion of individual letters into sounds and progresses to syllables, words, phrases, and sentences. Decoding is a prerequisite skill for reading comprehension because if one cannot decipher the words, one cannot comprehend the text.' The following questions must be answered in assessing decoding skills. Does the child have an adequate sight vocabulary to allow for fluent reading of text? This can readily be assessed by word recognition subtests on tests such as the K-TEA and WJPB. The second question is more difficult to answer. How well does the child use word analysis skills, including phonetic analysis and structural analysis skills, to unlock unfamiliar words?
Downloaded by: University of Pennsylvania Libraries. Copyrighted material.
ASSKSSMEN'I' A N D RE:ME:I)IKI'ION O F 1,E:AKNING DISABII~I7'IES-DAKIN
46
The clinician should have an in-depth knowledge of word analysis skills in order to assess them accurately. (Lernerlg includes a short phonics quiz to assess the teacher's knowledge of phonics and a brief review of phonics generalizations in her excellent textbook on learning disabilities.) Does the child know the sounds associated with the letters of the alphabet as well as the consonant and vowel combinations? If the child has a firm understanding of these sound-symbol relationships, does he apply this knowledge when he is reading? Does the application of this knowledge break down when the child encounters two or more syllable words? Does the child accurately read common prefixes and suffixes? The following tests are helpful when assessing word analysis skills. T h e Word Attack subtest on the WJPB and WJPB-R uses nonsense words to assess a child's word analysis skills because the child cannot recognize the words as sight words and therefore has to rely on his word analysis skills to decode the words. T h e Decoding Skills Test (DST)"' is a diagnostic, criterion-referenced instrument that assesses a child's ability to use word analysis to read unknown words. It compares word analysis skills and word recognition skills using words in isolation versus contextual material. An assessment of oral reading fluency is also included as part of this test. It is important to include an assessment of oral reading fluency as part of a complete reading evaluation because the dyslexic reader usually exhibits dysfluent oral reading and requires specific remediation to improve this skill. Finally, the DST also includes a measure of comprehension. The DST can be used with readers on the first to fifth grade levels. Extensive research supports the relationship between phonologic processing difficulties and reading difficulties."-I" Because of this relationship, I recommend including an assessment of phonologic skills as a component of a complete reading assessment. Sparks et al" suggest that phonologic, syntactic, andlor semantic processing deficits can interfere with the acquisition of foreign language skills at the college level. They suggest using the Goldman-Fristoe-Woodcock Auditory Selective Attention Test2' and the Goldman-FristoeWoodcock Sound-Symbol Tests, subtests 1,4,6,7,23 for probing phonologic problems involving auditory discrimination of sound elements, auditory blending of sound elements, memory for sound elements, and auditory distractability. In addition, I suggest using the Blending subtest of the WJPB, the Sound Blending subtest of the WJPB-R, and the Lindamood Auditory Conceptualization Test'" as possible diagnostic tests for assessing phonologic abilities.
V 0 1 , U M E I I , N U M B E K 1 ILZARCH 1901
The dyslexic child's decoding skills are usually poorer than his reading comprehension skills. He is able to compensate somewhat for poor decoding skills by using context, but inevitably comprehension is compromised by lack of automaticity. If the dyslexic child also has attentional problems, it is difficult for him to exert the attention needed to make good use of context and therefore he is less likely to be able to compensate for his poor decoding skills. An assessment of handwriting is important because many dyslexic children have significant handwriting problems. Initially, they often have difficulty recalling how to form the manuscript letters and may confuse letters that are similar except for their position in space, such as b,d,p, and cl. They may also use an atypical grip and have difficulty with proper spacing, the letter-size relationship, and the spatial organization of the page. l'he transition to cursive handwriting is typically not made smoothly and usually requires extra help and effort. Often the child reverts back to printing because the transition is not completed. Cursive handwriting should be encouraged because it flows and therefore, once mastered, should be more efficient. Cursive handwriting is likely to decrease the possibility of reversal errors. It is interesting to note that dyslexic children may have difficulty with handwriting, but may be very talented artists and very creative with their use of three dimensional forms such as building toys and blocks. Dyslexic children usually have significant difficulty with spelling and therefore spelling should be carefully evaluated. The Boder Test of ReadingSpelling Patterns'Qategorizes spelling errors into the following types: spelling errors of the auditorvphonetic (dysphonetic) type, visual-spatial (dyseidetic) type, or the most severe, the mixed type, involving errors of both types. Researchers have challenged the distinction between linguistic and visuo-spatial types of spelling errors and have found that types complicated by the presence of ADHD were unstable over time.lPThe Test of Written Spelling-2 ('I'WS-2)"' assesses a child's ability to spell predictable words, words governed by spelling rules, and unpredictable words or irregular words. The TWS-2 appears to have adequate reliability and validity,' but often is not a particularly helpful diagnostic instrument because the categorization of a number of included words as either predictable or unpredictable is questionable. These two tests are not recommended because they may not produce meaningful diagnostic information. A skilled clinician should be able to determine the kinds of spelling errors a child makes from an informal assessment of a child's spelling by carrying out an error analysis of his spelling errors both
Downloaded by: University of Pennsylvania Libraries. Copyrighted material.
S E M I N A K S I N NEUKOI,O(;Y
ASSESSMEN?' A N D KEMEDIA71'ION OF I.EAKNIN
