CCPR: How can we as child psychiatrists know that a child is getting proper treatment for a learning disability?
Dr. von Hahn: That is a really thorny question. Most individualized education programs are supposed to have measurable annual goals. But a huge number of the IEPs that are written only have general, but not measurable, objectives. If you have a research-based reading intervention for either general or special education, there are ways in which progress is tracked. Unfortunately, accurate measurement of progress in writing or math are less reliable. You and the parents will have to rely on information provided by the school to document progress.
CCPR: It sounds like writing and math are the two areas where there is still a lot to be done.
Dr. von Hahn: Yes, and reading comprehension is a bit of a can of worms, too. By grade three you are supposed to be reading paragraphs and understanding them. But it’s hard to measure comprehension. Writing can get complicated, too. Writing a five paragraph compare/contrast essay is not the same as writing a poem, but both are included in English Language Arts programs. Measurement in these areas varies by school district.
CCPR: Has the research shown any neurobiological basis for learning disabilities?
Dr. von Hahn: There is a high heritability for reading disability. If your patient has dyslexia, then there is a 40 percent chance that a first-degree family member also has a reading disability. In identical twins it jumps up to 60 or 66 percent (see for example, Monogr Soc Res Child Dev 2007;72(3):vii-l44). To read, the brain has to make connections between the language center and the visual perceptual center, mapping sounds and symbols. There are some MRI studies that show where dyslexia is located, but a child’s brain is so plastic that even if you have atypical brain development, other parts of the brain can take over. So why certain kids have dyslexia and others don’t is not clear. The neurobiological basis for writing and math disabilities is not researched very well.
CCPR: What about comorbidity with psychiatric disorders?
Dr. von Hahn: The research is unclear about the numbers, but it’s clear that comorbidity is really high. For example, children with ADHD have a up to a 70% percent chance of LD (Mayes SD et al, Learning Individual Differences 2006;16(2):145-157). There is high comorbidity between disruptive behavior disorders and learning disabilities. There is a slightly lower correlation with depression and anxiety, but the incidence of LD is still higher than what you would expect for the population as a whole.
The quality of testing and the identification if LD are very dependent on local and state standards.
~ Erik von Hahn, MD
CCPR: How do you think we should approach treatment of psychiatric comorbidity like ADHD in children with learning disabilities?
Dr. von Hahn: If a child has bona fide ADHD, it is likely that he or she is going to perform better in school with stimulants. so, go ahead and treat the ADHD. The child will probably socialize better and follow instructions more successfully. What is not clear is whether the stimulants actually enable a child to learn more. I respect the parents’ preference if they choose not to use medications. In any case, it’s important to provide good LD instruction and really good instruction on organization skills if a learning disability is present.
CCPR: What else do you think we as child psychiatrists can contribute?
Dr. von Hahn: You should be aware that school teams may or may not always provide the identification services or the educational interventions that the child needs. So you really have to understand local practice and point families in the direction of other resources if you think the child is going to be underserviced by the school. Education in general, and special education in particular, is underfunded. A lot of kids really could get to a high school level diploma by the end of grade 12 if they were given the right services.
CCPR: Thank you, Dr. von Hahn.