by Sanford Shapiro, Director, Bend Learning Center

Arguably one of the most important developments in therapeutic programming is the growing appreciation for the impact of learning disabilities on other areas of cognitive functioning, particularly those related to emotional and social development. As Mr. Shapiro highlights, the impact of deficits in one domain is rarely, if ever, without impact on others. Whether you are a line staff or a consultant, these issues are critical to understanding a student’s needs.

—Michelle Grappo, IECA Associate (CO)

Integrating knowledge from mental and behavioral health with best practices culled from cognitive science is crucial to understanding how therapeutic programs can improve outcomes. Knowing how learning disabilities and the neuro-developmental conditions of ADHD/executive functions deficits and Autism Spectrum Disorder (ASD) affect behavior and mental health should be a current and ongoing goal for the therapeutic community. According to experts, upward of 60% of adolescents in residential treatment centers for substance abuse have learning disabilities (National Center 2000). Enrollment data from all types of therapeutic programs indicate that students with ASD and ADHD contribute to and even add to those numbers. Consequently, it’s imperative that programs and schools become better informed about what science and clinical practice tell us about those conditions and how they affect mental health.

Self-Esteem

Historically there has been a clear and continued awareness of the burdening effect and weakening of self-esteem in students with a history of learning disabilities and related conditions. Schools and programs have been relatively quick to recognize the negative effects that stem from unspoken student thoughts, such as “I’m not good enough” and “I’m not smart.” Going further down that path, however, perhaps the most damaging aspect is the mindset of reduced self-efficacy, or belief in the effectiveness of one’s own efforts. The Frostig Center’s landmark study (Goldberg et al. 2000) was one of the early ones to signal this. Students with LD, ADHD, and executive function deficits suffer from a limiting belief that their efforts don’t have much to do with the results they see in their lives. This is the real meaning of “learned helplessness.” Further, such students perceive that most interventions, regardless of intention or potential effectiveness, are done to them. Partnership becomes much more difficult to achieve.

Processing

When I am involved in faculty training, one of the most common misunderstandings I run into involves issues related to processing. The ways in which information (verbal and nonverbal) is processed have huge effects on how and whether such students process therapy as well as classroom instruction. When a student who struggles to effectively organize spoken language (and even bright dyslexic students can struggle with this), too much talk therapy is, well, too much talk. This is no trivial matter. I remember the moment when my own stepson advocated for himself by telling us that when he calls home, he doesn’t want his mom and I on separate phones talking with him at the same time. He gets overwhelmed with the amount and density of language. Now imagine a high-powered and emotionally charged group therapy session.

Some students need appropriate setup and an effective debrief. Some may also benefit from some version of what’s called skeletal outlining during such a session. It’s important to ask a student even during an individual therapy session to recap the main issues and possible solutions that were covered. In addition, we know from science and practice that creating schematic visual representations—picture a flow chart or decision tree, for example—helps support weaker language processing and short-term and working memory. Lastly, students who have such language-based learning disabilities, including dyslexia, may also struggle to effectively produce precise language on demand. In a therapeutic context this can look like a teenager who is withholding or even dishonest unless one looks under the hood, cognitively speaking.

Autism Spectrum Disorder

Although it’s outside the scope of this article to discuss all the complexities of students with an Asperger’s presentation, here are a few important paradigms and observations that are based in part on my time as an executive director of a school where 60% of students had Asperger’s Syndrome or nonverbal learning disabilities. Much of the literature discusses weaknesses in reading the social and nonverbal cues of others. Most programs are at least partially familiar with these issues. What gets less or little attention is the flip side of this, namely weaknesses resulting in underrecognition of their own nonverbal signals. As a result, stress management becomes infinitely more complicated. Literature indicates that the neurobiology of autism spectrum involves right hemisphere weakness, an underperforming insula and an overactive amygdala. Such neurological characteristics help us understand why some students fail to recognize their own signs of distress, why hygiene is an on-going issue, and why relatively neutral interactions can seem so threatening. One of the main jobs of the insula is to register and move sensory information from the body and emotional (limbic) centers to the thinking and metacognitive parts of the brain. We have to wrestle with this, to explicitly work on these areas when treatment planning. In general, students with these types of deficits may benefit from somatic therapies, aspects of mindfulness, and visual-spatial supports.

Resource Pool Depletion

Barkley (2012), one of the world’s most respected authorities on ADHD and executive function deficits, outlined the concept of resource pool depletion. In essence, every time someone with executive function deficits engages in a task that demands these self-regulation skills, their execution function fuel tank is depleted further. Research helps us recognize what to do and how to build up these resources as well as avoid unnecessary depletion. I find that front line staffs of therapeutic programs are hungry for more knowledge in this area.

One of the longstanding and often helpful operating paradigms in therapeutic programs is “natural and logical consequences.” Learning through the experience of mistakes and their consequences feels intuitive and seemingly bulletproof from criticism; however, it’s important to recognize its limitations in terms of what research tells us. Addicts often defy that logic, for example. We know that the powerful forces of addiction often disobey that type of learning from mistakes. These conditions all contain a common denominator: powerful chemical, neurological undercurrents. Consequently, simply waiting for the light bulb to go on for those with significant ADHD and executive function deficits is often an exercise in futility. They don’t suffer from a lack of knowing what to do. They suffer with issues of performance. Without knowing how to offer the right types of supports at the points of performance, teachers and therapists are left to repeatedly apply consequences. It can be a vicious cycle that engenders repeated failure.

Final Thoughts

Not all therapeutic program providers need to become experts in ADHD, ASD, and executive function disorders, but learning how to apply awareness of these special needs will help all students. This is referred to as a universal design approach. Building sidewalk ramps for folks in wheelchairs helps people with sprained ankles, skateboarders, and parents with strollers and carts. Similarly, employing best practices in reading instruction helps able readers to become advanced readers. This is my hope for integration between disciplines.

Sanford Shapiro can be reached at [email protected]

References

Barkley, Russell A. 2012. Executive Functions: What They Are, How They Work, and Why They Evolved. New York, NY: Guilford Press.

Goldberg, Roberta J., Eleanor L. Higgins, Marshall H. Raskind, and Kenneth L. Herman. 2000. “Predictors of Success in Individuals with Learning Disabilities: A Qualitative Analysis of a 20-Year Longitudinal Study.” Learning Disabilities, Research and Practice, 18(4): 222–236. http://frostig.org/wp-content/uploads/2015/09/20-Yr-Qualitative-2003-Goldberg-et-al.pdf

National Center on Addiction and Substance Abuse. 2000. Substance Abuse and Learning Disabilities: Peas in a Pod or Apples and Oranges? New York, NY: Columbia University. www.casacolumbia.org./addiction-research/reports/substance-abuse-learning-disabilities