Podcast Transcript

ADHD and Learning Disorders

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Summary:
In this episode of the Pocket MD podcast, psychiatrist Eugene Arnold and pediatric neuropsychiatrist David Marks discuss ADHD and learning disorders. The medical term, "specific learning disorder," is used for clinical diagnosis while the education and legal systems use the term "learning disability." Specific learning disorders frequently co-occur among children and adolescents with ADHD. Around twenty percent of children with ADHD show some accompanying learning delay or challenge. The challenges are most often in acquiring academic skills such as reading, mathematical skills development, and written expression. The co-occurrence of these disorders predicts worse mental health outcomes than if the conditions exist independently. Trained practitioners who can properly diagnose and prescribe interventions that involve the child's parents and educators can help to minimize poor outcomes and improve overall trajectories for the child.

Eugene Arnold, MD, Med
L. Eugene Arnold, MD, MEd, is professor emeritus of psychiatry at The Ohio State University, where he formerly was the director of the division of child and adolescent psychiatry and vice-chair of psychiatry. He is a co-investigator in the OSU Research Unit on Pediatric Psychopharmacology. He has forty-five years of experience in child psychiatric research, including the multi-site NIMH Multimodal Treatment Study of Children with ADHD (“the MTA”), for which he was executive secretary and chair of the steering committee. For his work on the MTA, he received the NIH Director’s Award. A particular interest is alternative and complementary treatments for ADHD. His publications include ten books, more than seventy chapters, and more than four hundred articles.

David J. Marks, PhD
David Marks, PhD, is a clinical associate professor of child and adolescent psychiatry and the director of educational outreach for the Neuropsychology and Learning Service at the NYU Child Study Center—Long Island Campus. His research activities have focused on the roles of neurocognitive and familial factors in the expression and course of ADHD as well as the development of therapeutic interventions for individuals with the disorder. Dr. Marks has authored or coauthored more than sixty articles and book chapters and has served as a reviewer for scientific journals in the areas of child psychopathology and pediatric neuropsychology. He also conducts and supervises comprehensive neuropsychological evaluations, consults with teachers and school-based support teams, and assists with the identification and implementation of educational and therapeutic interventions.

Learning Objectives

  1. Identify the different types of learning disorders.
  2. Explain how the symptoms of ADHD and learning disabilities can overlap and how they can be distinguished.
  3. Learn about the interventions available for a child who has ADHD and learning disorders.
  4. Learn how parents can support their children who have learning disabilities.

 

The following transcript has been edited for clarity.

Announcer (00:00): You are listening to Pocket MD training on ADHD in children and adults.

Dr. Eugene Arnold (00:07): Hello, welcome to Pocket MD. The topic for today is learning disorders, learning disabilities, and ADHD. I'm Dr. Gene Arnold, professor emeritus of Psychiatry and Behavioral Health at Ohio State University and CHADD's Resident Expert. As it happens, relevant to today's topic, I also have a master's degree in education. Our guest today is Dr. David Marks, who is an expert in both ADHD and learning disorders. And David, would you tell us a little bit more about yourself?

Dr. David Marks (00:50): Sure, I'd be happy to. Thanks so much, Gene. My name is David Marks. I'm a clinical associate professor of child and adolescent psychiatry at the NYU Child Study Center. In that capacity, I conduct comprehensive neuropsychological evaluations of children, adolescents, and young adults, including those with learning related challenges accompanying ADHD, comorbid or accompanying anxiety, depressive disorders, developmental issues, and children on the autism spectrum. So, I'm delighted to be joining you today to speak about a topic near and dear, specifically ADHD and learning disorders.

Dr. Eugene Arnold (01:37): To start off, maybe we should define what learning disabilities are. Are there different kinds of them like there is for ADHD with three presentations and how prevalent are they in children with ADHD?

Dr. David Marks (01:52): Sure. That's a great place to start. Learning disabilities or specific learning disorders, as they're commonly referred to, reflect unexpected or unanticipated difficulties involving one or more areas of learning. When we say unexpected, we mean that these are learning challenges that are not better explained or accounted for by intellectual delays, uncorrected sensory issues like vision or hearing delays or impairments, a lack of proficiency in English, inadequate instruction, or for that matter, chronic absenteeism. So, we're talking about challenges that significantly disrupt the normal pattern or process of learning. When such difficulties involve reading and impact the ability to make sound-symbol associations, that pattern is referred to as dyslexia. It can also impact mathematical skill development, commonly referred to as dyscalculia, or for that matter, elements of written expression, which is known as dysgraphia.

By definition, learning challenges need to be persistent and last at minimum of six months. Further, an important component of our understanding is that learning differences need to persist despite interventions that have been mobilized to target the areas of difficulty. As with most conditions, learning problems must, by definition, create significant impairment and interfere in with one's ability to manage educationally or professionally, or perform daily activities requiring those skills, like calculating a tip at a restaurant or reading certain signs that might be needed.

To your question about the co-occurrence of ADHD and learning disorders, it has been approximated that upwards of around twenty percent of individuals with ADHD also meet criteria for one or more specific learning disorders, which themselves tend to track or co-occur quite frequently. When we think about the prevalence of specific learning disorders, learning disabilities involving reading, or dyslexia, are far and away the most common. They impact about eighty percent of those identified as learning disabled. It's therefore not surprising that it has been the educational sphere in which resources have really most intensively directed.

Dr. Eugene Arnold (05:15): We know that both ADHD and learning disorders can interfere with academic achievement and performance. How can you distinguish between the two problems and what symptoms overlap and what distinguish them?

Dr. David Marks (05:31): Yes, that's a really interesting question. Conceptually, both conditions have the potential to interfere with educational performance or aptitude. It might be best to think of specific learning disorders in reading, math or writing as really impacting or more selectively interfering with the skills that govern their development, phonological awareness in the case of reading, for instance. We also know that individuals with ADHD struggle to engage in activities that are effortful or resource demanding, which for some, may involve areas of scholastic aptitude such as reading? Individuals with learning disorders may show avoidance in ways that resemble what we see among individuals with ADHD. So, what's likely different is that the attentional limitations that we see in specific learning disorders when ADHD is not present are apt to manifest primarily in academic as opposed to other situations.

So, on the whole, I would say it's best to think of ADHD as a condition that impacts performance as opposed to skill development per se. I would also underscore that when ADHD symptoms occur alongside specific learning disorders or disabilities, effective management of ADHD symptoms, which I suspect we'll be talking about in a little bit, can certainly improve or enhance their availability for learning and ability to respond favorably to intervention. And again, it's really important given that the co-occurrence of learning challenges and ADHD seems to predict worse mental health outcomes than learning challenges without ADHD.

Dr. Eugene Arnold (07:36): So it sounds like there's a synergism or potentiation of the two disorders. Each one makes the other worse.

Dr. David Marks (07:43): I think that's certainly very fair.

Dr. Eugene Arnold (07:46): How common is misdiagnosis confusing the two problems and maybe trying to treat the wrong one?

Dr. David Marks (07:53): It's a good question. I'm not sure it's a question that one could readily answer, but I would say that there are apt to be a few steps or measures that may mitigate the risk of misdiagnosis. The first would be to align with a professional when there are suspected learning challenges to ensure that a detailed background and collateral records—like report cards and standardized test scores—are acquired. It is also important that evaluating professionals to engage in conversations with teachers or learning specialists to ensure that they obtain a comprehensive understanding of the child’s learning.  The second would be to pursue a comprehensive evaluation to try to tease apart the contribution of each entity; that is the contribution of ADHD symptoms versus learning related challenges. We may also encounter a disconnect between how a child performs in an office assessment, which is a controlled, individualized setting, and how the child performs day-to-day in a school setting, which is a less idealistic type of situation.

Dr. Eugene Arnold (09:11): What kind of skill set is needed to diagnose learning disorders? What specialist would be needed to diagnose learning disorders, and can the same person diagnose both the ADHD and the learning disorders?

Dr. David Marks (09:26): That's a really good question. Any number of providers with the requisite training can diagnose ADHD and learning disorders. As a pediatric neuropsychologist, these are skills that have were actively incorporated into my own training. As a group, pediatric neuropsychologists are well positioned to understand both learning challenges and accompanying behavioral and emotional needs, if applicable. School psychologists may also be positioned to understand both of those situations. And then clinical psychologists with the proper training may also evaluate individuals for both ADHD and learning disorders.

Dr. Eugene Arnold (10:13): If a physician suspects learning disorder, how would they go about making a referral for the learning disorder evaluation? They would have already diagnosed or ruled out ADHD.

Dr. David Marks (10:27): That could be approached in any number of ways. A referral can either be made through the child's school to better understand their learning needs and their profiles. Alternatively, an independent practitioner can address those questions as well. I would say that the role or the purpose—the mission, if you will—of a school official, differs somewhat from that of an independent practitioner. The role of a school provider is to size up or determine eligibility for educational services or supports as opposed to arriving at a formal diagnostic determination. Those determinations are typically made by independent providers.

Dr. Eugene Arnold (11:13): There was a study, the ICARD [Interventions for Children with Attention and Reading Disorders] study some years ago that compared medication and specialized tutoring for children who had both ADHD and learning disorder, and they found that the treatments were very specific. The medication did not help the learning disorder and the tutoring did not help the ADHD, but each of the specific treatments helped its own disorder. So what kind of interventions are available for a child who has both disorders?

Dr. David Marks (11:48): Yes, I really appreciate your bringing up that study. I think efforts to address the co-occurrence of ADHD and a learning disability are, as you alluded to, Gene, are ideally addressed through evidence-based strategies known to target each condition. So, in the case of ADHD, that may encompass behavioral and/or pharmacological interventions to manage the core symptoms of ADHD and some of the accompanying difficulties that manifest around executive functioning, particularly in later childhood and adolescence. For reading, that may encompass an evidence-based, multisensory phonics-intensive reading program that's broadly referred to as an Orton-Gillingham approach. Educators can also assist through program modifications and testing accommodations, such as audiobooks, having questions or items read to students, and additional test-taking time.

Writing is such a unique case. It's probably one of the most complex, multifaceted, activities we ask kids to do. So, the nature of the intervention needs to be coupled to the nature of the delay or the deficit. Broadly speaking, we think about graphic organizers, assistive technology, guided practice around specific writing rules, and perhaps some interventions to target fine motor delays. In the case of math, again link the intervention to the challenge, whether it be drilling around facts, spatial difficulties, if those apply in lining up math problems, or underlying executive function issues such as organization or the multi-step nature of math problems. Again, this really underscores how integrally critical our evaluations are because they serve as such an effective roadmap for driving areas of intervention.

Dr. Eugene Arnold (14:02): It's interesting that, as you pointed out, that writing involves several different skill sets, and one of them has to do with hand coordination and fine motor skills. A lot of children with ADHD have a thing called developmental coordination disorder, and it's different from the learning disorders that you described, but it may interact with them, and it's possible that if the child's only problem is writing, maybe it's due to the coordination disorder rather than a learning disorder, one could then use interventions like dictating homework or things like that would be a different sort of accommodation than you would've used for the learning disorder. But what age would be ideal to assess a child for learning disorders? We know that ADHD can be diagnosed as young as age four, but what would be an appropriate age if you suspect a learning problem for which they should have an assessment?

Dr. David Marks (15:06): In much the same way as parents of youth with ADHD report that the precursors of ADHD symptoms predated when a diagnosis was assigned, the same can be said for learning delays. Thus, the signs of a struggling learner typically precede the onset of the reading, writing, or math issues per se. We may see speech and language issues early in development, trouble understanding or processing auditory information, motor delays, and/or problems expressing frustration appropriately. Our diagnostic manual, or the DSM-5, states that learning difficulties can be identified once formal instruction has started, but we also know that educational challenges may not really take hold or manifest in a significant way until the demands on an individual exceed their capacities. And for individuals that manifest strong or above average intellectual abilities, those capacities may shield or protect them from showing more frank learning differences until adolescence. Overall, while learning problems can be identified any time after formal instruction starts, they may not take hold until later, and our measures are most sensitive in teasing out some of those differences at or beyond seven to eight years of age.

Dr. Eugene Arnold (16:49): There are a couple other disorders that are relevant or related here. One of them is auditory processing disorder. How does that relate to learning disorders or ADHD?

Dr. David Marks (17:00): That is something that we encounter quite often in clinical practice. Auditory processing disorder is generally conceptualized as a breakdown in the ability to accurately process or discriminate acoustic signals and is thought to operate independent of auditory acuity. So, we're not talking about individuals who have hearing loss, but rather folks that struggle under less- than-ideal acoustic conditions. This includes high levels of ambient noise (others talking around them, an announcement on the loudspeaker), or auditory signals or communication that is degraded (if something is muffled, perhaps), or if input is delivered to both channels or ears simultaneously. It is typically under one or more of these conditions in which we see evidence of processing difficulty, even though again, their auditory acuity per se seems to be intact.

Dr. Eugene Arnold (18:17): Okay. Another disorder that is relevant here is autism spectrum disorder, which includes some perceptual processing problems and sensory problems. One of the subtypes of autism has been called nonverbal learning disorder and which has also been called Asperger's, but in any event, it's been included now in the autism spectrum disorder diagnostic category. Could you comment on how that might interact with these other issues that we talked about?

Dr. David Marks (18:52): It's fascinating because Nonverbal Learning Disorder, or NVLD, has been addressed within the scientific literature now for decades, certainly well into the 1980s, as I recall, perhaps well before that even. But it is conceptualized a bit differently than Specific Learning Disorder or problems with reading, math, or written expression. And, unlike those disorders, the DSM-5 does not outline or specify criteria at this time for a Nonverbal Learning Disorder, even though the markers have been extensively discussed. In a nutshell, individuals with a Nonverbal Learning Disorder, as the name implies, struggle with processing or management of nonverbal information. They may show difficulties with spatial analysis or appreciation of visual patterns and directionality, and a number of collateral abilities tend to be impacted: motor skills, inferencing, nonliteral language, computational skills, and executive functioning. Also, we often find that individuals with NVLD struggle with nonverbal aspects of communication— reading facial cues and/or reading between the lines—and the often show elevated levels of anxiety and/or depressive symptoms.

In contrast, they may present very well verbally. Many describe them as auditory learners, and while distinctions between a Nonverbal Learning Disorder and Autism can be a bit hazy, I would argue that there are a number of ways in which they do differ meaningfully. To your question of impact on ADHD symptoms and how the coexistence of that pairing may impact your presentation, I think in our experience clinically, what we see is that, relative to an individual without a Nonverbal Learning Disorder, the presence of a Nonverbal Learning Disorder tends to make the educational presentation more challenging, and their social and emotional challenges more salient. On the whole, they tend to show a more impaired presentation relative to those who present with ADHD by itself.

Dr. Eugene Arnold (21:30): It's interesting that the symptoms overlap between autism spectrum disorder and learning disorders, particularly in the sensory area. So that's an interesting area for further research in the future. But I'd like to ask you, what can parents do to support kids with learning disorders? What can they do at home?

Dr. David Marks (21:57): The first thing they can do is to be vigilant, to be engaged, and to be close partners with their child's educators to maintain a pulse on their kids, educationally, behaviorally, socially, and emotionally. If there are indicators, particularly early indicators, it is important to actively pursue a comprehensive evaluation. We know that trying to address learning challenges and ADHD symptoms earlier in development can foster more favorable outcomes. So, making use of before or after school instruction, enlisting a tutor, minimizing distractions in the child's workspace, and assuring that the assigned work or the practice that parents complete with their kids at home is at a level at which their mastery or success can be achieved. It is also important to make sure that those working with kids actively support their effort, not just their outcomes.

Dr. Eugene Arnold (23:03): Is there anything else that you think should be brought out to complete the picture that we're talking about? Maybe summarize the highlights and take away points?

Dr. David Marks (23:15): The only other thing that I would say relates to how these challenges can manifest. So, when we're talking about reading, it may reflect any aspect of the reading process, be it letter-sound identification, sight-word reading accuracy, decoding, comprehension, and fluency or speed. In the case of math, it might be number sense, retention of math facts, and/or the accuracy or efficiency with which children are able to perform operations. It may also involve math reasoning, which itself can be impacted by other things like reading or working memory abilities. And as we discussed earlier, writing is such a complex task, and delays can impact everything from spelling, sentence composition, grammar, punctuation, and/or the organization and clarity of written output. So, in each of these different areas, we're talking multifaceted underlying skill sets, and an evaluation could be so integrally important to creating that roadmap.

To summarize, Specific Learning Disorders frequently co-occur among children and adolescents with ADHD, and approximately one fifth of youth with ADHD also show an accompanying learning delay or challenge. Learning issues themselves also often track closely together, such the co-occurrence of reading and math issues. And interventions for ADHD and the accompanying learning challenge(s), which may be distinct from one another, as you indicated, Gene, can certainly move the needle, enhance their confidence and self-esteem, and improve their overall trajectories.

Dr. Eugene Arnold (25:17): Thank you for a very informative discussion of this common clinical problem. I guess we've come to the end of the time now. Okay. Thank you.

Dr. David Marks (25:27): Thank you so much, Gene.

Announcer (25:29): Pocket MD is brought to you by CHADD with funding from the US Centers for Disease Control and Prevention, and in partnership with the Rainbow Center at Rainbow Babies and Children's Hospital.