Neuropsychological Aspects for Evaluating Learning Disabilities

Abstract

This review surveys the empirical literature for assessments of learning problems in children from a neuropsychological perspective. An evaluation of children with learning problems must consider measures of working memory, attention, executive function, and comprehension (listening and written), particularly for children who do not respond to intervention. These constructs must be tied to intervention techniques, and their connections must be empirically verified. The response-to-intervention (RTI) perspective provides excellent support for the process in young children but is still developing the process for students above the second grade. This review provides information about the existing research on neurobiological correlates of learning disabilities, possible areas for further evaluation, and the link to the RTI movement.

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JOURNAL OF LEARNING DISABILITIES
VOLUME 38, NUMBER 6, NOVEMBER/DECEMBER 2005, PAGES 563–568
Neuropsychological Aspects for
Evaluating Learning Disabilities
Margaret Semrud-Clikeman
Abstract
This review surveys the empirical literature for assessments of learning problems in children from a neuropsychological perspective. An
evaluation of children with learning problems must consider measures of working memory, attention, executive function, and compre-
hension (listening and written), particularly for children who do not respond to intervention. These constructs must be tied to interven-
tion techniques, and their connections must be empirically verified. The response-to-intervention (RTI) perspective provides excellent
support for the process in young children but is still developing the process for students above the second grade. This review provides
information about the existing research on neurobiological correlates of learning disabilities, possible areas for further evaluation, and
the link to the RTI movement.
L
earning disabilities have been de-
fined in various ways over time.
Terms such as minimal brain dys-
function, word blindness, and dyslexia
were once widely used. The term learn-
ing disabilities became popular particu-
larly with the passage of P.L. 94-142 in
1975 (Goldstein, 1997). A definition
proposed by the National Joint Com-
mittee for Learning Disabilities in 1981
suggested that “these disorders are in-
trinsic to the individual and presume
to be due to central nervous dysfunc-
tion” (Hammill, Leigh, McNutt, &
Larsen, 1981, p. 340). This definition in-
cluded difficulties with reading, math-
ematics, listening comprehension,
written language, and expressive and
receptive language. Although the term
learning disabilities has been under-
stood to be a heterogeneous term, most
laypeople and many teachers interpret
it to mean difficulties in reading. The
empirical field also shows this empha-
sis on reading with the abundance of
articles about reading disabilities com-
pared with those written on mathe-
matics, written language, or social
learning difficulties.
Learning disabilities are comor-
bid with other diagnoses including
attention-deficit/hyperactivity disor-
der (ADHD), anxiety, and depression
(Martinez & Semrud-Clikeman, 2004).
ADHD has been found to co-occur in
approximately 20% to 50% of children
with reading difficulties, depending on
the method of calculating a learning
disability (Semrud-Clikeman et al.,
1992). ADHD has also been found to
co-occur with difficulties in mathemat-
ics (Semrud-Clikeman, 2003), written
language (Hargrave, Corlett, & Semrud-
Clikeman, 2002), and social–emotional
learning disabilities (Semrud-Clikeman,
2003).
Comorbidity of learning problems
with other diagnoses makes it impera-
tive to evaluate these possibilities
when developing a remediation pro-
gram for a child (Pennington, 1990).
Moreover, we are just beginning to un-
derstand the contribution of these re-
lated but separate diagnoses to learn-
ing. Far more research is available that
evaluates brain functioning in children
with reading disabilities than in those
with other learning problems or those
who show a combination of difficul-
ties. Although, because of restrictions
on length, the focus of this article will
be on reading disabilities, the other
areas of learning disabilities are equally
important and, I hope, can be high-
lighted at another time.
Learning disabilities have gener-
ally been identified through the use of
a discrepancy between measured abil-
ity (IQ) and achievement (Joshi, 1999).
As noted by other articles in this issue,
this type of assessment is very narrow,
does not directly lead to recommenda-
tions for remediation, and ignores the
various neuropsychological functions
underlying the ability to read, speak,
comprehend, write, and do mathemat-
ics well. This model also has difficul-
ties because it relies on a simple differ-
ence between two scores to determine
the presence of a learning disability
and provides little information as to
the predicted learning curve of the
child or adolescent being evaluated.
Moreover, this practice has also been
found to overidentify those children
with high IQs and average achieve-
ment and underidentify those with
lower IQs and below-average achieve-
ment (Birch & Semrud-Clikeman, 2002;
Semrud-Clikeman et al., 1992).
The acknowledgment of deficient
brain functioning in children with learn-
ing disabilities has become more widely

JOURNAL OF LEARNING DISABILITIES
564
accepted, particularly with the advent
of research evaluating the functioning
of the brain. A discussion of the most
recent findings about the neural struc-
tures involved in reading may high-
light the various aspects of the learning
process that need to be evaluated.
Brain Imaging and
Learning Disabilities
Emerging findings suggest that chil-
dren with learning disabilities process
information differently from those with-
out learning problems. Differences in
development have shown that fluent
adult readers utilize the frontal regions
more than do children who are begin-
ning to read (Schlaggar, 2003). The left
frontal region becomes more active
over the course of development, and
more fluent child readers activate this
area more than do children with diffi-
culties (Schlaggar et al., 2002). More-
over, children with learning problems
show a differential pattern compared
with normal readers; they activate the
parietal and occipital areas more than
the frontal regions, and also show
more activation in the right hemi-
sphere than in the left. This finding is
important because activation of the left
hemisphere, a region specialized for
language functions, plays an impor-
tant function in reading.
The change from posterior systems
in early reading (visual–perceptual pro-
cesses) to frontal systems by more flu-
ent readers suggests that the progres-
sion from simple letter and word
calling to comprehension requires a
maturation of neural pathways from
the back of the brain to the front (S.
Shaywitz, 2003). Moreover, children
show a more diffuse activation when
they begin learning to read that gradu-
ally becomes more specialized as their
reading improves. Similarly, when nor-
mal readers were asked to read single
words, they showed left hemispheric
activation, whereas those with dyslexia
showed more right hemispheric activa-
tion (Breier et al., 2003; Papanicolaou,
2003). Changes from right hemispheric
processing to left hemispheric process-
ing have been found to occur with im-
provement in reading skills. These
changes are also found when improve-
ment in language functioning occurs.
Such changes are not found for chil-
dren with dyslexia, as their reading
process does not become automatic
and effortless.
Gabrieli (2003) found that the re-
gion most responsible for auditory
processing and language is more acti-
vated in good readers than in those
who had compensated for their dys-
lexia. These researchers found that
more activation correlated with higher
scores on reading measures. These
studies also found that improvements
were found in activation following re-
mediation of auditory processing abil-
ity. It is not clear at present whether
these changes continue over time. Fur-
ther study is needed to understand
possible brain response to remediation.
The Neuropsychology of
Learning Disabilities
An evaluation that centers solely on
the simple process of subtracting, or
regressing IQ from achievement, is a
narrow one that misses many of the
difficulties frequently seen in these chil-
dren. The processing of information is
a complex and distributed operation.
To evaluate the child’s learning skills,
one must understand the child’s ability
to process language, to understand
what he or she hears, and to organize
information; the speed with which the
child processes information; and the
child’s attention, ability to hold infor-
mation in mind while solving a prob-
lem, and ability to self-monitor the
reading process.
Language difficulties have fre-
quently accompanied problems in learn-
ing to read. These language problems
may be in receptive or expressive lan-
guage. The phonology of the language
can be tricky to master. Language is a
natural process of our brain, and brain
structures are devoted to its develop-
ment. Reading, however, is an acquired
skill that children must be directly
taught. When a child has a language
problem in addition to reading deficits,
the progress is much more difficult.
Approximately 70% to 80% of children
learn phonological coding skills with-
out difficulty. The remaining 20% to
30% show differing levels of success,
and based on previous studies, the de-
termining aspect may be the interven-
tion provided as well as the child’s
overall verbal skills.
The ability to decode words is a
fairly well-known area of difficulty for
children with learning disabilities; how-
ever, more recent research indicates
that the main difficulty is not just the
decoding of the word but also the rate
of decoding (Joshi, 1999; Woodcock,
1991). Speed of information processing
separates fluent from nonfluent read-
ers (Semrud-Clikeman, Guy, & Griffin,
2000). Children with reading disabili-
ties are slower at naming words and
nonwords as well as at naming letters
and numbers (Aaron et al., 1999).
An important aspect and goal for
reading is comprehension. The same
cognitive processes mediate listening
comprehension and reading compre-
hension, but they do so through a dif-
ferent modality (Joshi, 1999). Assessing
the ability to process information with-
out the confound of decoding allows
one to more fully evaluate the child’s
ability to understand and process lan-
guage and to determine whether the
difficulty lies with decoding or com-
prehension. An evaluation of these
skills is necessary to understand where
the breakdown in skills lies and, thus,
to develop the most appropriate inter-
vention.
An additional neuropsychological
process that is important to reading
skills development is working mem-
ory. Working memory is the ability to
hold information in mind while solv-
ing a problem, remembering a phone
number, or decoding a word. Working

VOLUME 38, NUMBER 6, NOVEMBER/DECEMBER 2005
565
memory is a crucial skill for early read-
ing recognition and later reading com-
prehension; one must assess it if one is
to develop the most appropriate method
of intervention (Teeter & Semrud-
Clikeman, 1997).
Adele Diamond studied working
memory in young children. She had a
child observe her hiding an object and
then asked the child a few seconds
later where the object was. Children
younger than 1 year could not find the
object and used the rule of “Out of
sight, out of mind.” Before age 1, the
frontal lobes are unable to process de-
layed information. However, as chil-
dren grow, they become more able to
retain information for a short amount
of time while processing information.
To decode words, the child’s working
memory must be functional and allow
the child to retain a “template” of the
letters until the word is sounded out. If
a breakdown occurs in the ability to
hold this information in mind, or if the
time required recalling the sound–
symbol relationship is prolonged, the
child will experience difficulty reading
(Semrud-Clikeman et al., 2000).
Working memory has also been
linked to the ability to organize a task’s
temporal aspect. Not only is input en-
coded; the task is also tagged to a time
when it was learned (Gazzaniga, Ivry,
& Magnum, 2002). The prefrontal cor-
tex is linked to memory systems that
allow the child access to previously
learned materials. If difficulty is pres-
ent at the outset, or at the working
memory stage, the child will have
difficulty recalling previously learned
skills (i.e., the letter c in c-a-t has a cer-
tain sound), and thus decoding will be
slower and effortful. Similar difficulty
arises in spelling and in learning math-
ematics. For example, in mathematics
the child needs to remember certain
mathematics facts as well as when to
use a particular procedure.
Executive functions are also skills
that are important for the learning
process. These skills apply to how
something is accomplished rather than
just to what is accomplished. They
help a child evaluate his or her perfor-
mance, and they also inhibit response
to irrelevant stimuli. The selection of
what is important to encode is essential
in learning to read, write, and do math-
ematics. In addition, a child needs to
learn to listen to what he or she is read-
ing (either orally or silently) and eval-
uate its correctness. This skill becomes
more important in older grades, as the
child must self-correct mistakes. The
awareness of “how I’m doing” is cru-
cial to the learning process and allows
the child to change behaviors or to take
corrective action as necessary. These
skills do not come into full fruition
until early adulthood, and some would
suggest that not until we are 32 years
of age do we have a fully mature brain
(Denckla, 2003). Thus, an important
issue to assessment would be to evalu-
ate the child’s ability to understand his
or her thinking processes.
Learning Disability
Identification Process
Remediation suggests that an under-
standing of the underlying processes
in learning have been evaluated, either
formally or informally. The multitier
process suggested by response to in-
tervention (RTI) ties assessment to in-
tervention for those children requiring
more specialized and intensive treat-
ment than is available in the first tier or
in the general education classroom. A
feature of RTI is academic and behav-
ioral screening with a valid assessment
measure and continued monitoring if
substantial progress has not been dem-
onstrated. However, the screening tool
to be used is not defined or even ex-
plained. This difficulty is reminiscent
of the original definition of a learning
disability that required a “significant
discrepancy” but did not define what
significant entailed. Such ambiguity
has plagued this field and appears to
be continuing. Recommendations for
better defined specific tools or mea-
sures are important to help standard-
ize these procedures nationwide.
The research base for learning dis-
abilities has been complicated by diffi-
culties with definitions. States vary in
how learning disabilities are defined;
definitions range from few criteria to
very stringent. In Texas, for example, a
child can be identified as learning dis-
abled by a 16-point standard score
point discrepancy, whereas in Minne-
sota, the discrepancy must be more
than 2 standard deviations. Moreover,
a child who does not meet criteria for a
learning disability in Texas but who
shows at least an 8-point discrepancy
from IQ is classified as dyslexic. Such
unevenness of definitions makes iden-
tification of these children as well as
determination of appropriate interven-
tions for them more difficult.
The RTI model suggests that for
some children, identification would
not occur until they had failed, and use
of the model may lead to denial of ser-
vices to some children clearly at risk
for learning disabilities. A full assess-
ment would also not occur until after
the child had repeatedly failed at some
of the interventions. Although the goal
to tie how the child responds to inter-
vention has interesting possibilities,
the difficulty lies in how this response
to intervention is evaluated. If this
process is considered evaluative, then
psychometric properties for the assess-
ment need to be developed and at this
point are not provided.
Emerging evidence also indicates
that particular times in development
may be most advantageous for reme-
diation. The developing brain learns
new information through a set of neu-
ropsychological processes, and these
processes lay down new neural con-
nections that, once formed, may be dif-
ficult to reteach. Also important from a
neuropsychological point of view is
the finding that the brain is most ready
to learn these connections within cer-
tain points of time, namely between
the ages of 5 and 8, and for higher level
thinking skills from the ages of 12 to 15
(Teeter & Semrud-Clikeman, 1997).
The longitudinal study of dys-
lexia by S. Shaywitz (2003) found that

JOURNAL OF LEARNING DISABILITIES
566
poor readers who had compensated
for their difficulties through remedia-
tion utilized brain areas that were dif-
ferent from those used by readers who
continued to have difficulty. More im-
portant, the children who showed
compensation not only had higher ver-
bal ability scores than those who did
not; they also attended less disadvan-
taged schools. A control group received
the “usual” interventions and showed
very little improvement. By delaying
intervention until failure, the compen-
sated systems may not develop, or
they may develop less well than with
younger children. The study of the
time window in which remediation is
most effective has not been fully com-
pleted, but response to intervention
may differ depending on the age of the
child.
A partial solution may lie in de-
veloping appropriate screening instru-
ments that can assist in isolating those
children most at risk for later difficul-
ties and tracking their progress care-
fully through the early school years.
The multitier system can easily utilize
this procedure, but agreement is needed
as to what the most important aspects
are that are evaluated and monitored
early on. In addition, besides behav-
ioral measures, measures that tap neu-
ropsychological constructs such as at-
tention or working memory could be
incorporated into this screening.
Coupled with these concerns is
the suggestion that children with
learning problems be provided in-
struction in the regular classroom until
significant failure occurs. This model
assumes that the regular education
teacher has been taught the skills
needed not only to identify children
with learning problems but also to de-
vise an intervention to offset these dif-
ficulties. Most of the RTI research has
centered on children in kindergarten
and first-grade classrooms. Very little
empirical evidence suggests that this
program is appropriate for children at
older ages. Prior to implementation of
this program for all children, studies
with children in middle school and
high school must be conducted to de-
termine the appropriateness of the
model for children of this age. In addi-
tion, sorting out variables such as at-
tention and emotionality that may also
be part and parcel of a reading problem
is important.
Such assessments require special-
ized skills among staff, and experience
in administering these measures is re-
quired in a comprehensive individual
assessment. To achieve the laudable
goal of introducing regular education
professionals to working with these
children, it is necessary to provide ad-
ditional education for these teachers,
as well as providing master teachers
for support. Understanding the nature
of learning is also important. The link
from neuropsychological processes to
intervention has not yet been forged,
but the previous section on brain imag-
ing suggests that there is much to un-
derstand about how we learn which
will, one hopes, lead to appropriate in-
terventions.
The simple RTI model incorpo-
rates several features that are very use-
ful in our understanding of learning
disabilities and, more important, our
understanding as to appropriate inter-
ventions. The implementation of a uni-
versal screening procedure for speci-
fied skills is very useful. Moreover,
tying this screening procedure to proven
effective interventions is invaluable.
These steps are necessary for the iden-
tification of children with learning dis-
abilities but are insufficient for the fol-
lowing reasons.
First, the evaluation is skills fo-
cused and does not provide informa-
tion as to the ability of the child to gen-
eralize learning or to complete more
inferential or abstract tasks. This em-
phasis on skills may be appropriate for
early grades but becomes less appro-
priate for higher grades, beginning at
around Grade 4. For example, a child
may be able to read all of the words in
a passage but may not be able to com-
prehend the meaning behind the words.
A child in first or second grade may not
show a significant problem in this area,
but if this difficulty continues into
third grade and beyond, the problem
becomes more serious; it transcends
the reading class and has implications
for content courses such as science and
social studies as well as mathematics
word problems.
Second, RTI is unable to differen-
tiate learners with varying learning
needs. A child with an attentional prob-
lem may have a reading problem, but
the appropriate intervention is not the
same as one for a child who has de-
coding difficulties. Both children may
respond to small-group instruction,
but for different reasons. When these
children are reintroduced to the larger
classroom, the likelihood is high that
the child with attention problems will
not succeed—not because he or she
cannot do the reading, but because he
or she cannot follow through on the
work (Semrud-Clikeman et al., 1999).
The RTI framework does not directly
acknowledge the contributions that
can be made by neuropsychology and
thus lacks an integral part of our un-
derstanding of how children learn and
process the world around them.
A possible solution to these seem-
ingly discrepant models would be the
melding of the neuropsychological
framework and RTI into a more com-
plex model. Such an integration would
contribute to our understanding of
children who are not responding in the
manner that we would expect in the
initial tiers of RTI. Screening children
on predictor variables such as working
memory, attention, and executive func-
tions would be helpful not only to
monitor progress but also to “catch”
children who are a higher risk of not
responding to the intervention at an
earlier stage. The use of cutoff scores
could readily be incorporated into the
screening already routinely completed
by RTI. These measures are not time-
intensive and can provide additional
information for the teacher and the par-
ent and for older children themselves.
Performance that is more than 1 stan-
dard deviation below expectations for
the age of the child should be closely
monitored, and children scoring 2 stan-
dard deviations below average should
be referred for an evaluation to rule out

VOLUME 38, NUMBER 6, NOVEMBER/DECEMBER 2005
567
any conditions that may interfere with
their progress. Moreover, those stu-
dents that do not respond to the early
stages of RTI are appropriate for a
more comprehensive evaluation to de-
termine why they are not responding
to appropriate interventions.
Summary and
Conclusions
Educational practice is at an exciting
time in development. Not only have
we evidence that children with dys-
lexia (and possibly other learning dis-
abilities) have brain differences com-
pared with typically reading children;
emerging data indicate that they re-
spond relatively quickly to brain-
based and comprehensive teaching ap-
proaches that have empirical support
(Berninger, 2003). Additional findings
indicate that the most effective in-
terventions are those that involve sys-
tematic instruction that is explicit and
continues throughout their school
experience (B. Shaywitz, 2003). More-
over, predictions of response to inter-
vention are best completed by neuro-
psychological measures of language
and attention rather than through the
use of a discrepancy model (Stage, Ab-
bott, Jenkins, & Berninger, 2003). These
findings support the use of a multi-
method evaluation of skills required
for successful reading. Strassner,
Semrud-Clikeman, and Gerrard-Morris
(2003) found that teachers have lower
expectations of academic performance
from children who have ADHD or
learning problems. These expectations
may, in turn, lead to less attention in
the classroom and fewer appropriate
interventions.
One of the most important con-
clusions from research is that for chil-
dren with learning problems, learning
is hard work. A corollary to this find-
ing is that for their teachers, instruction
is very hard work and requires an
enormous amount of training and sup-
port. Children who have difficulty
learning to read or completing mathe-
matics problems will likely not benefit
from “more of the same” but require an
alternative method of teaching to assist
their learning.
Until now, we have emphasized a
specific type of educational placement
(resource or inclusion). However,
based on the data from neuroimaging
studies, we need to develop methods
from scientifically supported instruc-
tional strategies, and we need to un-
derstand whether different types of
interventions are interchangeable or
work as efficiently for most children.
Work on this aspect of RTI has not been
completed.
The definitional struggle that has
characterized the field of learning dis-
abilities is continuing. An important
piece of this puzzle, which has been
missing in the debate, is how children
respond to various interventions and
how we can match the intervention to
the difficulty. We have several years of
experience showing that the “usual”
method of teaching reading works for
most children and with an adjustment
(going from phonics to look-say, etc.)
works for many children who cannot
profit from a single method. What we
have not fully discovered, and what is
now developing, is the ability to work
with those children who have been de-
fined as “treatment resistant,” that is,
those children who do not seem to
profit from either general approach.
We also need to learn how these chil-
dren may differ early on, so that our in-
tervention can occur before significant
failure sets in.
The multitier approach to inter-
vention has much promise, but again,
we need to prepare our teachers so that
they are best able to identify the chil-
dren who need a fuller evaluation of
their abilities. Given the findings from
the neuroimaging and neuropsycho-
logical fields of deficient performance
on measures of working memory, pro-
cessing speed, auditory processing
ability, and executive functions, evalu-
ation of these skills is necessary to de-
termine the most appropriate program
to fit the individual child’s need. The
danger with not paying attention to in-
dividual differences is that we will
repeat the current practice of simple
assessments in curricular materials to
evaluate a complex learning process
and to plan for interventions with chil-
dren and adolescents with markedly
different needs and learning profiles.
ABOUT THE AUTHOR
Margaret Semrud-Clikeman, PhD, is a pro-
fessor in the Department of Educational Psy-
chology at the University of Texas at Austin and
is the program director for the APA-accredited
School Psychology Program. Her research in-
terests include neuroimaging in developmental
disorders, interventions for children with ADHD
or nonverbal disabilities, and neuropsychologi-
cal assessment. Address: Margaret Semrud-
Clikeman, PhD, Department of Educational
Psychology, 1 University Station, D 5800, Uni-
versity of Texas at Austin, Austin, TX 78712;
e-mail: peg.semrud@mail.utexas.edu
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