CCPR: Dr. Montalto, to begin, can you briefly tell us what you do at NYU?
Dr. Montalto: As the clinical director of the Institute for Learning and Academic Achievement, I evaluate children and teens for learning disabilities, developmental disabilities, and neuropsychological impairments, including ADHD. We work toward understanding the ways children learn and helping them pursue academic endeavors and overcome barriers that get in their ways.
CCPR: A large proportion of the patients of child psychiatrists undergo neuropsych or educational testing, but we don’t always know exactly what information you need from us to best test the kids.
Dr. Montalto: What is really helpful is a detailed history, with documentation of things like attention difficulties in the child’s history. If language and motor milestones were reached on time is also important. We also need a detailed family history, especially with information on learning disabilities, because what we know from the literature is that there is a genetic link. We want to know if the parents themselves had similar struggles, even if there was no formal diagnosis.
CCPR: And once the testing is complete, how best should child psychiatrists use the results when treating our patients?
Dr. Montalto: The results can help guide treatment goals, and further explain triggers that lead to moodiness, irritability, sadness and anxiety. When you get the results of testing from a patient, there are a few things to look out for. The most critical piece is that if it’s been more than three years since the testing was completed, it needs to be updated. Early elementary school is when most kids present for testing, but it can be as early as preschool. It’s around the six or seven year mark is when teachers and parents start to see red flags in basic reading, foundational skills, and math development. Another thing to look for is whether you have all the information you need. For example, say a child has results from an IQ test and some academic testing, but you sense the child’s articulation is weak; you may want to get additional testing targeted at language development.
CCPR: Are there any diagnostic pitfalls when assessing kids with learning and developmental disabilities? For example, can one “disorder” actually be reflective of something else entirely?
Dr. Montalto: One big thing that both psychiatrists and psychologists see is confounds with selective mutism. We are beginning to learn that there can be some real language impediments underlying this disorder, in addition to, or rather than, just anxiety. I’ve developed a testing battery that doesn’t require the child to verbalize responses. You also want to be sure hearing and vision tests are up to date. Another diagnostic pitfall is “absence seizures.” Sometimes kids with these appear to have ADHD—since they seem not to be paying attention and staring into space—when in fact they are having seizures.
CCPR: Can you talk a little bit about the subtle learning disabilities? Like auditory processing disorder?
Dr. Montalto: With auditory processing difficulties, you have to try to get a sense of whether a child has difficulty differentiating sounds when there are other distractions around. This is hard, because kids with ADHD can look very distractible and as if they are only grasping certain words. This is why a speech and language evaluation that targets the auditory area is important. So if you are seeing some inattentiveness, especially when you are talking to the child with no distractions, he or she may not actually understand everything that you are saying. If his or her responses are a little off or you are not sure if the question was understood, you should further evaluate whether there is a speech and language impediment.
CCPR: Now contrast that, if you will, with a processing speed difficulty.
Dr. Montalto: Processing speed typically means that when the child is given a straightforward and clerical paper and pencil measure, like copying a key, that child is very slow at processing the information and getting the work done. This is usually captured with a diagnosis of learning disability not otherwise specified. It’s important to note processing speed, because we know that under different circumstances where time is not a factor, these kids will do really well—it is just this slow access to information that inhibits their performance. Also look at if they are making mistakes when they do this type of task. There is a big difference between being just slow but accurate, and not getting it right.
CCPR: And what if they are not accurate?
Dr. Montalto: That can reflect some impulsivity if they are working too quickly. They could have difficulty discerning visual objects, which is a visual spatial weakness. Or it could be that they work slowly and are trying to keep up, so they are not accurate in terms of what details they pay attention to.
CCPR: You would see that sort of disorder in the coding subtest of the WISC [Wechsler Intelligence Scale for Children]?
Dr. Montalto: Yes, on the coding and the symbol search. You may also see it with some Woodcock Johnson processing tests or any timed visual scanning task.
CCPR: Are there specific learning disabilities associated with an inability to spell?
Dr. Montalto: Weaknesses in spelling, as well as reading, are rooted in two main language areas: phonological awareness and rapid word retrieval. Phonological awareness is the understanding of sounds and how they make up words. So kids who typically have difficulty with phonological awareness may also have trouble with spelling.
CCPR: Could you talk a little bit about the kids with nonverbal learning disabilities [NLD]? You know there is this sort of diagnostic conundrum. Is this Asperger’s, or is this a nonverbal learning disability?
Dr. Montalto: Right. A lot of the controversy around this stems from the kids who have the social deficits characteristic of autism, but exhibit a lesser degree of language impairment. Currently, the marker that we use when trying to distinguish Aspergers from NLD is that Asperger kids tend to perseverate, and have more restrictive interests, than children with NLD. Children with a nonverbal learning weakness usually have weaknesses in math and fine motor skills as well as social difficulties. They are interested and trying to be social, but they are just off the mark a little bit, and they are not picking up on those cues effectively.
CCPR: So once we have identified that a child has a learning disability, are there ways we can help enhance functioning?
Dr. Montalto: That’s a great question. What is usually helpful is to do less, more frequently. What I mean is: say junior is having trouble with math. If he can focus on just five to 10 minutes of basic math review every day, that would be all he needs. He could use flash cards or a computer program. Consistency is what’s important. And you can make it fun. If a child is having language difficulties, maybe a daily game of Articulate or Scrabble might be perfect. In addition, it is important to recommend specific learning-based interventions, such as working with a trained learning specialist to develop compensatory strategies and to help remediate areas of weakness.
CCPR: What sort of parenting recommendations can we make to our patients’ parents in regard to learning disabilities? We’re often asked, “How much of this is behavioral?” In other words, “How much of this should I discipline and how much should I forgive?”
Dr. Montalto: This is a tough call for parents because they want to do what is best for their children, but they also really want to get that homework done! When kids aren’t compliant it can be very frustrating. Children should not be punished for their learning difficulties. These kids are often really motivated, but they get frustrated easily and sometimes having their parents on their backs makes them less likely to do their work.
CCPR: So how do you suggest parents balance this?
Dr. Montalto: Much like a child with ODD, a child with a learning disability needs support for his or her efforts, such as reinforcing and shaping the small steps toward a larger goal, and using transitional reminders and warnings to help them persist with their work. A lot of children with learning disabilities benefit from a “daily report card,” which is a way of highlighting goals and reinforcing the work they are doing, such as spending 10 minutes a day focusing on writing, even though they don’t like it and it’s really hard. It’s important for parents to show kids they are paying attention to the things they are doing well and not just the things they are having trouble with.
CCPR: Do you have tips for helping parents convey the information about learning or developmental disabilities to teachers?
Dr. Montalto: If the child has a testing report, the person who did the testing should be contacted. If the teacher and school are open to it, he or she should come for a meeting with them, so everyone can talk about this child’s life.
CCPR: Thank you, Dr. Montalto.