INTRODUCTION — Learning disabilities (LD) are a heterogeneous group of disorders characterized by the unexpected failure of an individual to competently acquire, retrieve, and use information. They are caused by inborn or acquired abnormalities in brain structure and function and have multifactorial etiology [1]. LD are the most severe, pervasive, and chronic form of learning difficulty in children with average or above-average intellectual abilities [2,3].
Definitions of LD vary. The main feature that is common to all definitions is academic achievement that is lower than expected based on the child's overall intelligence [4-6]. LD manifests as a failure to acquire reading, writing, or math skills at grade- and age-expected levels. LD is often accompanied by other challenges to learning, such as poor study skills and problems with executive functioning. (See "Specific learning disabilities in children: Clinical features", section on 'Factors affecting clinical expression'.)
The educational management and prognosis of LD in children will be presented here. The definition, epidemiology, clinical features, evaluation, and role of the primary care provider are discussed separately. (See "Definitions of specific learning disability and laws pertaining to learning disabilities in the United States" and "Specific learning disabilities in children: Clinical features" and "Specific learning disabilities in children: Evaluation" and "Specific learning disabilities in children: Role of the primary care provider".)
In some countries, the term "learning disability" is used to refer to intellectual disability (mental retardation). Intellectual disability is discussed separately. (See "Intellectual disability (ID) in children: Clinical features, evaluation, and diagnosis" and "Intellectual disability (ID) in children: Management, outcomes, and prevention" and "Intellectual disability in children: Evaluation for a cause".)
PREVENTIVE MEASURES — The management of the student with learning disability (LD) begins with quality instruction, even before the student is identified as having an LD. Inadequate exposure to quality instruction may account for the student's learning failure as early as kindergarten or first grade. It is generally believed that early intervention with quality instruction improves outcomes for all students with learning failure (including those with LD) and that it is more difficult to educate students with LD when they are older [7]. Thus, quality instruction should be provided early and before attempts are made to identify an LD. This is the rationale behind legislation introduced under the No Child Left Behind Act, which requires schools to provide "highly qualified" teachers as well as "responsiveness to intervention" services. These stipulations are also required under the reauthorization of general education law (Every Student Succeeds Act), which will be fully implemented by September 2017. (See 'Quality instruction' below and 'Responsiveness to intervention services' below and "Definitions of specific learning disability and laws pertaining to learning disabilities in the United States", section on 'Every Student Succeeds Act' and 'Mandated school based services' below.)
QUALITY INSTRUCTION
In general education classrooms — A consensus definition for "quality instruction" is lacking. Quality instruction in general education classrooms includes multiple components. A full description is beyond the scope of this review. The United States Department of Education provides the following list of teacher practices to be included in the definition of quality instruction in general education [8]:
●Spacing learning over time (ie, provide repetition of the same learning concept over time) [9]
●Combining graphics with verbal descriptions
●Using preworked sample solutions with problem-solving exercises
●Quizzing to promote learning
●Helping students to allocate their time efficiently
●Connecting and integrating abstract and concrete representations of concepts
●Asking deep explanatory questions to develop greater awareness of the material being taught
Even where there is consensus about what constitutes quality instruction, delivery of instruction is variable. For example, not all teachers have the knowledge or instructional expertise required to teach reading successfully, even teachers who specialize in reading instruction [10,11].
Lack of resources can also interfere with the quality of the instruction provided, even when delivered by an effective teacher. Access to information about quality instructional practices may improve teacher effectiveness. A series of practice guides that describe quality instructional practices for a variety of learners and curricular goals is available from the Institute of Education Sciences [12]. Another way to assess quality of instruction is to assess the use of evidence-based practices in general education. Evidence-based practices are used inconsistently across the United States [13].
Quality instruction for LD — Quality instruction is required for children with learning disability (LD), just as it is for general education students. A consensus definition of quality instruction for children with LD is also lacking. When making decisions about how to provide instruction to the student with LD, the initial step is to identify the specific components of reading, writing, or math that are causing the student's learning difficulty (evaluation). The next step is to review the evidence for guidance about the type of instruction that is most likely to benefit the student. The final step is to address practical considerations related to access of services (eg, legal requirements or requirements of local practices in the student's home school district).
Identification of students who may have LD and who may need specialized instruction is discussed separately. (See "Specific learning disabilities in children: Clinical features" and "Specific learning disabilities in children: Evaluation".)
General recommendations — The following guidelines for instruction of children with LD are provided by the Council for Exceptional Children [14]:
●Sufficient duration and intensity of instruction to allow the student to make progress
●Appropriately trained teacher/professional development for the teacher to provide the intervention
●Small group size to maximize learning, to provide feedback to the student, and to allow for individualized instruction
●Appropriate progress monitoring based on the student's performance to allow adjustments to the intervention as needed
●Instruction based on the best available evidence
●Consideration of factors other than the student's disability (eg, second language status, behavioral self-regulation skills, etc)
Specific examples of how to meet these criteria are outlined in the sections on reading disability, writing disability, and math disability. (See "Reading difficulty in children: Interventions" and 'Writing disability' below and 'Math disability' below.)
●Evidence base – Although the examples of quality instruction for LD that are described below are considered to be "researched" and even "evidence-based," it is important to understand the limitations of educational research. The basic pattern in educational research is that the researcher identifies, labels, and counts specific teacher behaviors and then attempts to determine the association between those behaviors and student outcomes. "Teacher behaviors" in this case refers to behaviors such as the teacher's organization of the lesson plan, the amount of repetition provided, the types of classroom groupings used, the types of technologies used, etc. Students must also be taught skills that they are developmentally or educationally ready to learn, a facet of educational research that is more difficult to evaluate but is addressed in some studies.
Different researchers select varying teacher behaviors or classroom features for study and use different terms to describe them. This makes it difficult to compare outcomes across studies. Thus, there is limited consensus about which terms to use to describe teacher practices, let alone define or describe quality teacher practices. Because teachers do not rely on any one behavior or teaching strategy, any improvement in student outcomes is likely to be due to a variety of teacher behaviors or practices acting together, making it difficult to determine which specific types of teaching behaviors or methods are the most effective.
In addition to these limitations, educational research often lacks methodologic integrity. For example, educational research studies often 1) do not have a randomized or experimental design, 2) do not describe or discuss what measures were taken to assure treatment integrity, and 3) use researcher-created outcome measures rather than standardized measures such as performance on a standardized test. These methodologic limitations make it difficult to know which teacher practices are associated with the highest effect size, if any. Use of researcher-created outcomes makes it difficult to predict how a student will perform when he or she is assigned tasks that were not specifically taught during the intervention.
All of the above factors make it difficult to draw firm conclusions about the nature of quality instruction. In one oft-cited meta-analysis of 180 studies of instructional practices for students with LD, the authors estimated that only 10 percent of the studies were of high methodologic quality [15].
Types of instruction — Two main types of instruction for students with LD are explicit (also called direct) instruction and strategy instruction. These methods are particularly important for students with LD but are also beneficial for students without LD. They do not interfere with the learning of average- or high-achieving students being educated in the same classroom setting.
Educational research makes a clear case for the importance of both explicit instruction and strategy instruction. However, practitioners have different opinions about the best ways to engage students in learning and the relative merits of explicit and strategy instruction. They are often implemented inconsistently [16-18].
Explicit or direct instruction — Special education is known for its tradition of "drill and practice," referred to as explicit or direct instruction. In its most basic form, explicit or direct instruction refers to instruction that is dedicated to the acquisition of basic academic skills, largely through repetition and by memorization. Although criticized for being a dull form of learning and for not addressing the higher-order thinking that is the ultimate goal of education, there is broad consensus among educational researchers that direct instruction is an important component of special education instruction.
Direct instruction typically entails frequent and direct measurement of clearly observable behaviors and responses, such as acquiring sound-symbol relationships in reading and spelling; printing and handwriting; or memorizing basic calculations in math. Progress must be measured frequently.
The specific skills taught during direct instruction should be taught in a logical sequence, with rational transitions from one set of basic skills to the next, until mastery is achieved [16]. Although direct instruction traditionally refers to instruction in basic academic skills, any form of instruction that insists upon rote learning of a skill can be referred to as direct or explicit instruction. Strategy instruction, discussed in the next section, is typically considered to be distinct from explicit instruction but can also be taught through rote memorization and practice.
A detailed discussion of explicit instruction is provided in reference [19].
Strategy instruction — Strategy instruction is an important component of quality instruction for students with LD. Strategy instruction refers to instruction in a process or a procedure that the student can use to approach learning systematically. Strategy instruction helps the student memorize what he or she needs to learn; detect and correct errors encountered during learning or task completion; monitor and revise tasks when needed; and reflect upon what was learned.
A strategy can be as simple as prompting oneself to check one's spelling errors, using mnemonics to memorize information, or underlining the topic sentences in written text to improve reading comprehension. Strategies can also be more complex, such as the strategy or set of strategies used to write a five-page essay or the strategy used to develop a deeper understanding of the material being learned. For example, in reading-strategy instruction, the student is taught to use a set of steps, such as stopping while reading to check comprehension; asking questions, such as, "What does this remind me of?"; making links with prior knowledge; etc.
Students with LD often fail to approach learning strategically and do not monitor their own comprehension and/or success. Failure to approach learning strategically may reflect the executive dysfunctions that are a common comorbid condition in students with LD. However, students with LD are unlikely to approach learning strategically, regardless of impairment in executive skills. They use excessive cognitive resources to perform basic academic skills (eg, reading decoding, spelling, calculation) and therefore have insufficient remaining cognitive resources to approach learning strategically or develop metacognitive awareness of what was learned. Provision of strategy instruction can help to circumvent these limitations.
Additional information about strategy instruction, with examples, is provided in reference [19-21].
Other methods — Other methods of quality instruction for students with LD include teacher behaviors, such as stating the learning objectives clearly, having a clearly organized lesson plan, teaching in a recursive manner (concepts and learning objectives are reviewed multiple times over the course of the lesson or of the unit), providing examples, and proceeding through the material in appropriately small steps, etc.
Successful LD programs provide teachers with professional development focused on specific teaching methods. The effective teacher imparts a positive attitude to the student(s); has a variety of texts, strategies, and teaching methods to provide both direct and strategy instruction; and uses ongoing assessment to continually tailor instruction to the student's ability level [22]. Teacher behaviors that are strongly associated with positive effect sizes include [23]:
●Presenting smaller amounts of material at a time
●Using small interactive groups [18,24]
●Using directed questioning
Peer tutoring is also considered to be an evidence-based practice and can have positive outcomes on student learning [18,24-26]. Peer instruction is discussed in more detail in the sections on writing and math disability. (See 'Specialized instruction in writing' below and 'Specialized instruction in math' below.)
MANDATED SCHOOL BASED SERVICES — In the United States, federal laws require that school districts provide students with learning difficulty with "responsiveness to intervention" (RTI) services, specialized instruction or special education, and/or accommodation and modifications in the general classroom. However, access to these services is highly variable.
Responsiveness to intervention services — RTI refers to the delivery of specialized educational or therapeutic services to students before they are identified as having a disability and before providing special education services in an Individualized Education Program (IEP). The student's response to intervention can help distinguish learning failure related to inadequate instruction from learning failure related to a specific learning disability (LD; or another disability). RTI is a legal term that was introduced into the Individuals with Disabilities Education Act (IDEA) in 2004. For students who are not succeeding academically, an RTI model is favored over an evaluation to identify an LD. RTI is not limited to students with LD. It applies to any student who is not performing successfully at school. (See "Definitions of specific learning disability and laws pertaining to learning disabilities in the United States", section on 'Individuals with Disabilities Education Act'.)
RTI services are provided before the student is tested for an LD or for another disability. RTI is intended to prevent the inappropriate placement of a student into a special education program. RTI should be used on a temporary basis only; it does not replace the delivery of special education services. The criteria for eligibility for RTI services vary by school district. (See "Specific learning disabilities in children: Evaluation", section on 'Diagnostic process'.)
The delivery of RTI is the responsibility of the general education teacher but can include other school professionals as well. RTI delivery is highly variable across school districts and states. Teachers in training report that they feel unprepared to deliver RTI services [27]. In a survey of public school teachers, few felt well-prepared to provide appropriate instruction to students with disabilities in inclusion programs [28]. Teachers in the field cite numerous barriers to the successful implementation of RTI, including lack of knowledge and training in RTI, lack of time, and excess documentation requirements (paperwork) [29,30].
A common model for RTI services consists of three tiers. Tier one instruction is equivalent to general education instruction, possibly with some differentiation to address the needs of diverse learners. Tier two instruction occurs for a select group of students, often those who are performing below the 25th percentile in the general education classroom. These students receive intensive instruction. "Intensive" is defined differently by different authors but generally refers to quality instruction that is provided in a small group setting (six students or less) with a focus on remediation of deficits to help the students achieve grade-level performance. This instruction is provided for 30 to 60 minutes per day, three to five times per week, for 6 to 24 weeks. Progress is measured frequently, and an estimate of the rate of improvement is made. Based on the student's rate of progress, he or she may be returned to the general education setting or may undergo an evaluation to determine eligibility for special education services [31]. In this model, "tier three" instruction is equivalent to special education instruction. RTI models are discussed in greater detail in references [32,33].
One of the reasons for the shift to an RTI model is that providing preventive services is considered to be better than waiting for students to fail. Support for this position is based on results of intensive, high-quality reading instruction, which shows greater effect sizes when the interventions are provided early (eg, in kindergarten or first grade, before LDs are typically diagnosable) as opposed to later.
It is not certain to what extent RTI will reduce the number of students identified as having LD [34]. The long-term merits of RTI have yet to be determined and will be difficult to measure because of the great variability in RTI practices across school districts and states [31,35]. At a minimum, RTI practices have been shown to improve screening and progress monitoring of students since their implementation in 2004 [30]. They also appear to have reduced referrals to and placements in special education [36-38]. The majority of RTI services are dedicated to reading instruction for young students, though there is no legal or educational reason to limit RTI services to reading instruction alone.
Evaluation for specialized instruction — Under IDEA, parents, teachers, and other professionals inside and outside of the school system can refer a child who is not succeeding academically for an evaluation to determine whether the child is eligible for special education services (specialized instruction). RTI services do not have to be provided before an evaluation takes place, though the period of RTI services can provide valuable information about the student's learning abilities and learning needs, including the type of testing that may be required during a subsequent evaluation. (See "Specific learning disabilities in children: Evaluation", section on 'Evaluation and identification of LD in school settings'.)
When the request for an evaluation is made in writing, schools have to respond with a proposal to conduct an evaluation (or to deny the evaluation) within five business days. The school can refuse to conduct the evaluation if an evaluation was done within the previous year or if they have data to show that the evaluation is not needed. If no evaluation has been completed recently, schools typically agree to the request for an evaluation. Once the parents have provided written permission to the school for the evaluation to begin, the school is obliged to complete the evaluation within 60 calendar days [39]. Specialized instruction for a learning disability begins after the school has created an IEP and after the student's parents have agreed to and signed the IEP. (See "Definitions of specific learning disability and laws pertaining to learning disabilities in the United States".)
Accommodations and modifications for students with LD in the general education classroom — This section provides examples of accommodations and modifications that may be appropriate for students with LD (table 1). Accommodations and specialized instruction can look similar. They can be provided as part of an IEP or as part of an Accommodation Plan. The legal criteria for an Accommodation Plan are discussed separately. (See "Definitions of specific learning disability and laws pertaining to learning disabilities in the United States", section on 'Section 504 of the Rehabilitation Act'.)
Accommodations are provided with the intention of simplifying or reducing environmental demands for the student. They are not necessarily designed to remediate performance deficits. In contrast, "specialized instruction" is provided to a student with the goal of remediation. However, the accommodations or modifications provided by a special education teacher or in a special education classroom can look the same as the instructional strategies (specialized instruction) described below. (See 'Specialized instruction in writing' below and 'Specialized instruction in math' below.)
Presenting smaller amounts of material at a time, using small interactive groups, providing more individualized direct questioning, and using peer group discussion can serve as accommodations or modifications and do not need to be considered as "specialized instruction." Strategy instruction and advance organizers (providing key information to the student in advance of a lesson) may also be used as accommodations or modifications. A more classic type of accommodation occurs when, for example, a student with a reading disability is allowed to have test instructions provided orally and to provide responses orally [40]. Dictation or scribing, or the use of preprinted lecture notes, may be used for students with writing disability. For all types of LD, the amount of time allowed to complete work (including a test) can be increased [41] or the number of items that the student is expected to complete can be reduced. These accommodations do not have the goal of remediating deficits.
Another type of accommodation or modification is to deliver the curriculum in a variety of ways. This is known as Universal Design and is most easily accomplished through the use of digital media [42,43]. Information can be presented using text, voice, or images. Text can be presented in varying sizes or can be presented as speech and/or in the context of images. Text can be presented with hyperlinks to associated glossaries, to related background information, to queries that support strategic thinking, and to tools that allow the student to express and organize text, recorded voice, or images [44,45]. Curricular materials that offer these options allow easier access to the general education curriculum for all students, and perhaps especially to students with disabilities.
READING DISABILITY — Specialized instruction for children with reading disability is discussed separately. (See "Reading difficulty in children: Interventions", section on 'Remediation' and "Reading difficulty in children: Interventions", section on 'Accommodation'.)
WRITING DISABILITY
Specialized instruction in writing — A teacher who knows that a student has writing difficulty needs to consider all of the components of writing and create an intervention plan to address the components that are the most affected. Lower-order writing skills consist of printing/handwriting (transcription skills) and spelling skills (a phonics-based skill that requires sound-symbol relationships). Ultimately, the student has to have memorized a certain number of high-frequency words and spell them automatically (writing fluency), without which higher-order skills are more difficult to master. Higher-order writing skills require the ability to write sentences (eg, understand language conventions related to punctuation, understand grammar) and to produce a composition.
Writing instruction involves drill and practice (explicit or direct instruction) of lower-order skills (transcription, spelling, and writing fluency) in the service of higher-order skills (writing sentences and compositions). Direct instruction is required for the student to achieve accurate letter formation and fluency in writing, spelling, and language conventions (punctuation and grammar). Improvements in these lower-order skills can improve higher-order performance. However, there are also specific types of instruction (eg, strategy instruction) that can be used to improve performance in higher-order writing skills [46].
The content of writing instruction for students with LD is not different from the content of writing instruction for general education students. "Specialized instruction" in writing thus consists of providing that instruction in smaller groups, frequent repetition and practice, more gradual transition from one skill to the next, and over a longer period of time.
Consensus about quality instruction for students with writing disability (WD) is less clear than it is for reading disability. There is no equivalent to the National Reading Panel to provide guidance or make recommendations for quality writing instruction. However, based upon the educational literature and research in writing instruction, writing instruction should consist of the following components [47]:
●Transcription skills – Automatic letter formation and handwriting skills are the first step to writing successfully. Handwriting/transcription is taught by direct or explicit instruction, through significant drilling and practice. Learning to write letters follows a logical sequence. Visually similar letters ("b" and "d"; "v" and "u"); letters with directional shifts ("z" and "s"); and less frequent letters ("q" and "w") are typically learned later than other letters. Printing and cursive are typically taught sequentially, but it is not clear that one should follow the other, nor that one leads to faster writing output than the other.
Handwriting (transcription) instruction is typically conducted by teachers, but occupational therapists, who focus on the motor components of writing instruction, also play a role. No one handwriting program is clearly superior to another, and the role of the occupational therapist in teaching handwriting skills varies within and between school districts [48].
In a 2011 systematic review of interventions to improve handwriting, twice weekly handwriting practice sessions for at least 20 sessions were found to be "effective," and recommended as the focus of intervention [49]. A 2016 meta-analysis of handwriting instruction corroborates the importance of handwriting instruction for improving higher-order writing skills (eg, writing sentences and writing compositions) [50]. Other motor or sensory therapies (eg, sensory-based training, relaxation) should not be the focus of the intervention. Once letter production skills are mastered, students can develop their personal handwriting style [51,52]. Learning to type may be preferred for older students or for students with motor impairments, especially when the focus is on writing compositions. (See 'Accommodations' below.)
●Spelling: Phonics skills – Phonologic awareness and phonics instruction are important components in spelling instruction. The value of phonologic awareness and phonics instruction in students with WD has not been studied specifically. However, they have been shown to help typically developing students improve their spelling skills. A small number of studies suggest that spelling improves as a part of reading instruction [53]. Teaching writing includes direct and explicit instruction in these language and reading skills [52,54].
●Writing fluency – Most spelling does not occur using a phonics-based approach. Rather, the student has to have memorized the spelling of a certain number of words, and has to transcribe them quickly from memory. Spelling improves with direct or explicit instruction in spelling that includes multiple practice opportunities and immediate corrective feedback when words are misspelled. Spelling instruction should include words that the student already knows how to spell, along with words that the student has not yet mastered. Spelling lists based on an individual student's spelling competence are a favored means of spelling instruction. Monitoring the student's progress and showing the student how many words he or she has mastered can enhance motivation.
Direct or explicit spelling instruction can only help students learn a small fraction of the total number of words that they will ultimately need to use in writing [54]. Thus, instruction in spelling as a part of text composition is recommended; this makes spelling more relevant and assures that it is an ongoing learning process. Spelling improves when the student is taught error correction strategies. Error correction strategies include having the student analyze his or her spelling and check for what is plausible; read (decode) the words aloud; have a peer read the word; read the text backward; or use a dictionary and/or computerized spell checker [53,54]. For older struggling writers, handwriting, spelling, and English language conventions can be taught in the context of composition skills.
●Writing compositions – Writing compositions is the ultimate goal of mastery in the lower-level skills discussed above. Writing compositions is complex because of the higher-order cognitive skills required for producing compositions successfully. Composition instruction requires significant strategy instruction. The specific strategies used by the student will vary according to the type of text that has to be produced and according to student preferences and needs (table 2). Some of the approaches for composition instruction are listed below:
•Writing strategy instruction – Strategies exist for writing at both the sentence and paragraph level [55]. The strategy should teach the basics of planning, writing, revising, and editing. The specific steps in the strategy can vary from teacher to teacher. What is important is that the teacher provides a strategy for writing and uses a consistent vocabulary to describe each of the steps (table 2). This facilitates the student's learning because it allows the teacher and the peers to analyze the steps of the writing process together. It also provides a mechanism for feedback and correction from the teacher and/or peers at each of the steps. Students with LD may learn the steps of writing strategy through direct and explicit instruction or in small groups. Students with LD can be taught to use the same strategies as students in regular education. (See 'Effective writing programs' below.)
Composition instruction requires teaching how to write different genres of compositions (eg, newspaper article, business letter, advertisement, personal essay, etc). Developing a shared vocabulary for the types of writing genres facilitates teacher-peer and peer-peer discussion and feedback.
•Provision of feedback – Composition instruction requires feedback. Feedback gives the student additional opportunities for planning, writing, and revising. Feedback from peers may be as valuable as feedback from the teacher and is important for the revising process, as well as to induce greater self-monitoring.
•Provision of accommodations. (See 'Accommodations' below.)
•Enhanced motivation – Students with WD may also need increased motivation (eg, by allowing them to choose their own topic) and more frequent and more structured opportunities to share their writing in a supportive environment [56,57].
Accommodations — Children with WD may benefit from accommodations, including:
●Extra time to master lower-order skills
●Extra time to understand, memorize, and apply writing strategies
●Small group instruction in writing steps
●For older children, use of a keyboard for lower-order weaknesses (eg, handwriting, spelling), allowing them to devote their mental energy to the ideas and organization of writing; this sometimes allows them to perform at a higher level of conceptual awareness than would otherwise be predicted and to write longer and better text [18,52]
Accommodations for writing compositions for children who have not mastered handwriting or spelling skills include:
●Use of pictures
●Dictation to a teacher
●Use of technology (eg, word processors, spell checkers, etc)
All of the accommodations that may be required by a writer can potentially be provided by a computer, which reduces the fine motor and physical demands of handwriting. Using a computer with word recognition, voice recognition, or dictation applications helps to reduce the number of strokes required to produce a word. Technology reduces the amount of work involved in correcting errors and reduces the problem of frequent erasures. In addition, computers help students with WD manage spelling errors and generate sentences, and may help with grammatic and stylistic errors. However, the effectiveness of technology to improve writing skills is uncertain. Lack of appropriately designed studies is one reason why the role of technology remains unclear [58].
Computerized writing programs also can help with planning, by providing outlines for specific kinds of text structures, or by prompting the writer with questions that help assure that certain kinds of content are included. For writers early in their writing development, computers can generate pictures and a variety of other media, which can be used to scaffold writing.
Finally, word processing and computers linked with one another can create a collaborative forum for writing to be shared, reviewed, and revised/edited by peers and teachers. Many of the accommodations listed here are used in writing instruction in the general education classroom and thus may not be accommodations in all circumstances [59,60].
Effective writing programs — Components of effective writing programs for general education students are the same as those for quality instruction for WD. Successful writing instruction includes teacher professional development in writing, an effective teacher, instruction in the components of writing, and maximum student participation. The use of peer-mediated instruction appears to be an especially favored instructional technique for teaching students how to write text because it provides a mechanism for obtaining feedback. (See 'Types of instruction' above and 'Specialized instruction in writing' above.)
Few effective writing programs are recognized in the educational literature. Two researched writing (composition) programs include the Self-Regulated Strategy Development (SRSD) writing program and Cognitive Strategy Instruction in Writing (CSIW), designed for general education students but also used for students with WD [21,61-63]. Both programs teach text composition skills by using a specific writing strategy. Students can work through the writing strategy over the course of several days. The strategy includes steps such as learning about different kinds of text structures, planning, writing an initial draft, revising the draft, obtaining feedback from peers and teacher, writing a final draft, etc. These programs can be used in conjunction with instruction in handwriting, spelling, and punctuation skills and can be used for students of all ages.
The general idea in SRSD, for example, is that the teacher presents information about a genre of writing (story, persuasive essay, news article) and about the specific steps for writing in that genre [62]. The steps of the strategy are identified by vocabulary chosen by the teacher and as dictated by the genre. The students learn about the type of writing they will do by analyzing examples and learning the vocabulary needed to discuss that genre of writing; they then learn the vocabulary for the strategy that is used to write in that genre (table 2). This step in the strategy is an example of direct instruction, because students are asked to memorize the steps in the strategy.
The students are then asked to work through each of the steps and to practice using the strategy in writing a composition. This is called guided practice: the teacher guides the student through each of the steps. Interactive dialogue is emphasized in this model, between teacher and student, between peers, and by using self-statements (thinking aloud with oneself as one writes). Dialogue with others and with oneself is used to monitor one's own use of the steps in the strategy but also to identify and overcome frustration during the task of writing. Over time, the dialogic component transfers the teacher's guidance to the student.
The multiple components of this example of strategy instruction include labeling and memorizing the steps in the strategy; memorizing a mnemonic for the strategy (table 3); having specific examples for how to complete each of the steps of the strategy; guided practice (the teacher monitors the student's use of the strategy); self-guidance (self-monitoring) using dialogue; and self-regulation (changing one's behavior to overcome barriers along the way). Dialogue is used to help the student monitor whether or not s/he completes each of the steps, and to identify and address obstacles (including frustration) along the way. The emphasis of this model is not simply giving the student a list of steps to follow but helping the student "own" the strategy by seeing it in action, seeing for him/herself how it gets completed, and even how the strategy can be modified by the student to meet his or her personal needs. Over time as the student matures, self-dialogue is internalized.
The instruction described above is appropriate for students with WD, as well as for general education students. The literature is not clear about the intensiveness of instruction required by students with WD. Students with WD may need intensive instruction in handwriting accuracy and fluency, spelling (including phonics instruction), and English language conventions. For students who are still mastering lower-order skills, writing compositions can be taught by teaching (oral) narrative skills and by use of dictation and/or pictures. Overemphasis on handwriting, spelling, text composition, or text meaning in isolation is likely to hamper the student's writing progress. All of the writing skills should be taught simultaneously as well as sequentially [52,53].
When all of the components of writing instruction are addressed, writing outcomes in students in both regular and special education improve. However, not all states include a writing component in state-mandated examinations. Consequently, not all states or school districts address writing skills as a formal part of the general education curriculum, let alone as part of the curriculum for students with LD [64,65]. The consistency with which writing instruction strategies are offered is highly variable across school districts and states.
MATH DISABILITY
Specialized instruction in math — Competence in math depends upon mastery of lower-order skills which are then used in the service of higher-order skills. In math disability (MD), primary deficits occur in number sense and in math facts (arithmetic combinations or arithmetic calculations). These two lower-order skills are necessary to develop competence in higher-order skills [66-68]. Performance in higher-order math skills also depends upon math fluency, ie, the fluent application of number sense and math facts. Students with MD also have difficulty solving word problems. This can be due to problems in number sense and calculation skills, or to a coexistent reading or language disability. Finally, visual-spatial and organizational problems can interfere with success in math. The clinical manifestations of MD are discussed separately. (See "Specific learning disabilities in children: Clinical features", section on 'Math LDs'.)
For a more detailed description of the difficulties faced by students with MD, see references [66,67,69-71].
Components of instruction — A true understanding of MD may be more complex than what is proposed here, as students may show other weaknesses as well [69]. However, the framework provided below serves as a starting point for discussing the content that should be addressed for students with difficulty learning math. The content of math instruction for students with math LD is not different from the content of math instruction for general education students. "Specialized instruction" in math consists of providing instruction in smaller groups, frequent repetition and practice, more gradual transition from one skill to the next, and instruction over a longer period of time.
Based upon "expert opinion," effective math instruction must address difficulties in the following areas [55,66,67]:
●Number sense – Number sense refers to having mental representation of quantity (ie, the ability to estimate and judge magnitude). It is an early-emerging skill that can fail to develop in students with MD.
Number sense is a prerequisite for math and is a teachable skill. It can be compared to phonemic awareness, which is a prerequisite for reading decoding, and is also a teachable skill. Number sense can be taught by practicing identifying or estimating quantity (less and more); 1:1 correspondence (eg, correlating the number of coins being dropped into a box with the sound each of the coins makes as it drops); serial ordering (numbers are always counted in the same order); "counting on" (ie, identifying changes in quantity by adding up from a smaller quantity to create a larger quantity); showing the link between addition and subtraction while using objects; using more than one type of visual representation for numbers (eg, a number line both horizontal and vertical); and other visual representations that show differences in size, volume, etc [70,71].
●Math facts or calculation skills – Number sense is required to understand how to add, subtract, multiply, and divide numbers. However, these skills are also acquired by learning the rules for addition, subtraction, multiplication, and division.
●Efficient and effective counting-strategy use – For students with MD, counting strategies need to be taught explicitly alongside number facts [66,67,72]. Students with MD may not develop their own strategic learning. For example, they may not learn that "counting upward" from the larger addend can save time when doing addition problems. Counting strategies can help develop both number sense and arithmetic combination skills [55,66,67]. As they become more proficient in counting strategies, students of math gradually develop memory-based retrieval of answers, which increases their overall efficiency.
●Math fluency – Automatic retrieval of answers to basic addition, subtraction, multiplication, and division of numbers is a prerequisite to solving higher-order math problems efficiently. Students with MD have difficulty completing higher-order math problems when they have not yet developed automaticity in basic arithmetic combinations and cannot retrieve memorized answers to basic arithmetic combinations quickly. Remediation is crucial for students who continue to have deficiencies in math facts at the beginning of third grade. Strategy instruction can help the student identify errors in their calculations and/or in their retrieved answers (eg, by using known number combinations, using associations between number combinations, etc). Drilling and memorization alone are not as effective as the combination of drilling with strategy instruction.
●Math vocabulary – Students with MD have difficulty with the language of math. They may reverse numbers or make errors when reading numbers aloud. Confusion about number symbols and signs (eg, "+," "-," "×," "÷," "=," etc) is a distinguishing characteristic of MD. In math, there are no context clues to help students decipher terms that they may not understand. The language of math must be taught directly and explicitly, not incidentally.
●Word problems – Reading difficulties can aggravate difficulty acquiring math skills. Students with a reading disability and MD have greater difficulty with word problems than students with isolated MD. They also have greater difficulty understanding the meaning of the sentences describing the problem, understanding what the problem is asking, and identifying extraneous or irrelevant information (see "Reading difficulty in children: Clinical features and evaluation", section on 'Clinical features'). General strategy instruction may be helpful in solving word problems (eg, "Read the problem; highlight the key words; solve the problems; check your work").
●Visual-spatial skills in math – Students with MD may have difficulty organizing math problems on the page. They may copy numbers incorrectly, write numbers illegibly, misalign numbers, have left-right disorientation of numbers, misplace digits in multidigit numbers, skip rows or columns during calculations, fail to carry numbers (eg, regrouping when appropriate), reverse number problems, start a calculation in the wrong place, or may not recognize operator signs. The use of lined or graph paper or specific strategy instruction to prevent errors such as these can help improve the student's performance. Visual spatial weaknesses can also affect the student's understanding of volume and math problems in geometry.
●Organization and planning in math – Students with MD have difficulty planning and organizing their approach to math problems. They have difficulty with multistep problems; they may fail to verify answers and may settle for the first answer they reach for a given problem. Teaching can include strategy instruction that requires the student to follow a prescribed sequence when solving math problems, to check solutions to basic math facts using a computer, or to prompt the student to ask if the answer is a reasonable one.
General teaching strategies — General teaching strategies that are important components of math instruction include [68,73,74]:
●Explicit instruction (drill and practice)
●Verbalizing the steps (think-aloud strategy)
●Immediate error correction and feedback
●Cumulative review
●Small group instruction
●Adequate practice opportunities
●Motivators
●Instructional design to minimize the learning challenge (eg, breaking math problems down into component steps)
●Frequent assessment and the provision of feedback to the student and the teacher alike
●Peer-assisted instruction
●Engage students by using their prior understanding to introduce new topics [75]
●Scaffold instruction (providing a scheme for teaching one skill; applying that scheme for teaching another skill; reducing the use of the scheme as new skills are taught) [76]
Effective math programs — Effective instruction in math is less well studied than effective instruction in reading and writing in typically developing children. The literature does not offer significant guidance for instruction for math LD. In one review of the effectiveness of math instruction in general education classrooms, no conclusions could be drawn as to what constitutes effective math programs. This failure to draw firm conclusions was due to the inadequate study design of the studies available for review [77]. As such, there are no specific math programs that can be recommended as "evidence-based," though there are evidence-based practices for some components of math instruction.
In a synthesis of effective elementary school math programs, the biggest effect sizes (which were in the small range) were for instructional process strategies, such as cooperative learning methods, in which students work in pairs or in small groups, or class-wide peer tutoring. These types of strategies are not specific to math instruction and are used in other subject areas as well. There were no significant effect sizes associated with the type of mathematic curriculum or with the use of computer-assisted instruction [78].
The recommendations listed below are taken from a practice guide produced by the United States Department of Education [79]:
●Instructional materials for students receiving interventions should focus intensively on in-depth treatment of whole numbers in kindergarten through grade five and on rational numbers (fractions) in grades four to eight (develops number sense, among other skills).
●Intervention materials should include opportunities for students to work with visual representations of mathematical ideas, and interventionists should be proficient in the use of visual representations of mathematical ideas (develops number sense). There is strong evidence for this recommendation.
●Interventions at all grade levels should devote approximately 10 minutes in each session to building fluent retrieval of basic arithmetic facts (math fluency).
●Instruction during the intervention should be explicit and systematic. This includes providing models of proficient problem solving, verbalization of thought processes, guided practice, corrective feedback, and frequent cumulative review.
●Interventions should include instruction on solving word problems that is based on common underlying structures. There is strong evidence for this recommendation.
●The progress of students receiving supplemental instruction and other students who are at risk should be monitored.
●Include motivational strategies in "responsiveness to intervention" models. (See 'Responsiveness to intervention services' above.)
●General teaching principles of effective instruction apply to math instruction as they do to instruction in other domains. For example, verbalizing the steps (think-aloud strategy); immediate error correction and feedback; small group instruction; adequate practice opportunities; motivators; frequent assessment and the provision of data as feedback to the student; and peer-assisted instruction are all important components in math instruction [70,80].
GRADE RETENTION AND SOCIAL PROMOTION — Grade retention is defined as the practice of having a student repeat a grade because of academic failure and is a common intervention for students who experience academic failure. The philosophy behind grade retention is that, if given another year to "catch up," the student's academic progress can improve over time. Proponents of grade retention may also say that students use the (undesirable) possibility of grade retention as a motivator to perform better. Social promotion is defined as advancing a student to the next grade even if he or she is not functioning at grade level.
The educational literature generally concludes that grade retention should be avoided [81]. Neither grade retention nor social promotion on its own is an effective educational intervention. Without classroom modifications and individualized instruction, students with learning problems, and especially students with learning disabilities (LD), will continue to experience learning difficulties, even after grade retention. Alternatives to grade retention and social promotion are discussed below. (See 'Alternatives to grade retention' below.)
Which students are retained? — There is no uniform practice for deciding how a student who shows academic failure is promoted versus retained. Many factors are associated with grade retention, including poor academic performance, behavioral regulation problems, poor attendance, and lower socioeconomic status. A disproportionate number of African American and Hispanic students are retained [82]. Another important factor that contributes to the practice of grade retention is the degree to which the school staff believes in grade retention as a useful intervention. A positive attitude among school staff toward grade retention increases the likelihood of grade retention [83]. Grade retention may be more common as a result of "high-stakes" testing that requires students to achieve a minimum score on statewide testing before being promoted. State-to-state variations in school expenditure and special education enrollment figures do not account for differences in grade retention between school districts. Grade retention is thus more dependent on individual, family, and neighborhood characteristics than on state-wide characteristics [84]. Grade retention that occurs early (eg, in kindergarten or grade one) does not appear to be more beneficial or more harmful than grade retention that occurs later [85].
Prevalence of grade retention — The data available to measure changes in the prevalence of grade retention are limited. A proxy for grade retention is the prevalence of students "below modal grade for age." Using this proxy, and correcting for late entry into school, the prevalence of grade retention is estimated to be between 10 and 20 percent in any given grade [86].
Is grade retention beneficial? — Most researchers do not believe that grade retention is effective for improving long-term outcomes [81]. Several outcome measures in grade retention research support this conclusion.
The outcomes measured in grade retention research include subsequent academic achievement, socioemotional status, and high school drop-out rates. When compared with same-age promoted peers, retained students show temporary gains in academic achievement and socioemotional status (behavioral regulation, emotional status, and peer acceptance), but these gains are not sustained over time [83,87,88]. An oft-quoted meta-analysis concludes that the majority of studies (95 percent) show that grade retention is associated with either no difference in effect (48 percent) or is associated with harm (47 percent) and should therefore be avoided [81].
Of specific concern is the association of grade retention with high school drop-out. Grade retention is considered to be the single most powerful predictor of high school drop-out, and students who drop out of high school are likely to have poor outcomes following high school, including lower wages and a lower likelihood of participating in postsecondary education, and to have poor employment competence ratings [89,90].
Although grade retention is associated with negative long-term outcomes, the limitations of grade retention research (described in the next section) do not clearly answer the question of whether it is grade retention, versus characteristics intrinsic to the student, that are cause for the negative outcomes.
Considering the multiple factors associated with retaining a student, including undiagnosed LD, socioemotional factors, poverty, lower parental participation in school, and poor attendance [90,91], it is not surprising that an intervention as nonspecific as grade retention does not, on its own, significantly improve student outcomes. Furthermore, grade retention is an expensive intervention, since the school district takes on the cost of educating the student for at least an additional year of schooling [92]. The cost of grade retention in comparison to the cost of providing remedial and/or special education services is not certain.
●Grade retention research – Studies on the effects of grade retention are problematic because of an absence of randomized design. Because of the lack of randomized design, the outcomes measures associated with grade retention studies may or may not be due to grade retention itself. Those students who are selected for retention are not likely to be the same (on myriad variables) as those students who are promoted. Thus, the outcome following grade retention may not reflect the intervention (grade retention), but may reflect intrinsic differences in the student who was retained, as well as other confounders.
Some authors attempt to control for the lack of randomization by matching retained students with promoted students on academic achievement and other variables. This may enhance the validity of the conclusions drawn, but it would not be possible to control all of the variables that might affect the student's performance. Additional limitations on grade retention research include the lack of:
•Control for treatment integrity (eg, not controlling for the proportion of retained or promoted students who receive supplemental educational services, such as special education).
•Control for attendance.
•Uniform control/comparison population – In grade retention studies, the retained students may be compared with their same-age (promoted) peers; with same-grade peers during the same calendar year; or with their promoted peers, once the retained student has reached the same grade. Such different comparisons yield different outcomes but are not necessarily accounted for in meta-analyses of grade retention.
All of these variables confound attempts to draw firm conclusions from the retention research literature as a whole. A more detailed discussion of grade retention research is available in reference [93,94]. In any case, given the many variables involved in academic failure, a nonspecific intervention, such as grade retention on its own, should not be expected to be effective.
Alternatives to grade retention — On their own, grade retention and social promotion are generally considered to be unfavorable strategies for students who are not succeeding academically [81,82,90,95]. Given the multiple factors associated with school difficulty (eg, undiagnosed LD, low self-concept, poor peer relations, poverty, poor attendance, etc) [90,91], it is preferable to determine the types of services, interventions, and accommodations that might help the student succeed over both the short and long term.
For many students, especially those who start school with fewer academic advantages than their peers, preventive intensive intervention, even before kindergarten, may be the best path to success. For students who are frequently absent, understanding and addressing the reasons for their absence should be considered. Retention usually duplicates an entire year of schooling. Other options, such as summer school, before- or after-school programs, or extra help during the school day, could provide the equivalent extra time that the student requires and could be instructionally more effective. Students who are not succeeding academically might benefit from multi-age classrooms, school-based mental health programs, and/or behavioral modification and social-skills training [82,90,96-98].
Teacher attitude and school culture may be just as important to address when considering grade retention as an intervention. In some cases, retention may be recommended as an educational intervention, even when the local school district offers other, more valid options to address learning failure [99].
SPECIALIZED EDUCATION PLACEMENTS — Educational remediation is a critical component of treatment and can be provided by the public school system through special education services, by special education private schools, or by private individual special education teaching services [17,100]. The eligibility requirements for special education within the public school system are defined by the Individuals with Disabilities Education Act (IDEA). However, there is wide variation in how students are selected for special education services by state and county. Schools may also provide specialized educational supports under the Americans with Disabilities Act, through Section 504 planning (504 Accommodation Plan). (See "Definitions of specific learning disability and laws pertaining to learning disabilities in the United States", section on 'Section 504 of the Rehabilitation Act'.)
Not every child with a learning disability (LD) will qualify to receive special education services under the umbrella of IDEA according to the guidelines in his or her school district. When such children are not eligible, it may be necessary for parents to provide specialized educational services privately. In seeking specialized education services for their child in school, parents may find it helpful to maintain a file of relevant documents. A list of important documents for parents to retain, as well as resources and information regarding state learning disability organizations, parent support groups, and advocates, are provided in the table (table 4), which may be printed and provided to parents.
●Services offered under Section 504 and No Child Left Behind – Schools offer many specialized services and accommodations to students, with and without learning disability. Services offered under the general education regulations (No Child Left Behind, now reauthorized as the Every Student Succeeds Act) and services provided under Section 504 of the Rehabilitation Act are typically offered in a regular education setting and can include an array of individualized academic supports, paraprofessional supports, and nursing and behavioral supports, among others. (See "Definitions of specific learning disability and laws pertaining to learning disabilities in the United States", section on 'Every Student Succeeds Act' and "Definitions of specific learning disability and laws pertaining to learning disabilities in the United States", section on 'Section 504 of the Rehabilitation Act'.)
●Services under the IDEA – Under the IDEA, the full range of academic and other supports, as well as a continuum of placements, is offered to qualifying students. Services can be provided in the regular classroom, special classrooms, special schools, and in home, hospital, or other institutional settings. Schools are obliged to provide services in the "least restrictive environment" (often abbreviated LRE). The legal definition of "least restrictive" means that, to the maximum extent appropriate, children with disabilities are educated with children who are not disabled [101]. Examples of the continuum are listed below:
•Primarily general education classroom – Children with LD who receive services in the regular classroom are "mainstreamed" with non-LD students for at least 80 percent of the day. The remainder of the day is spent in the resource room or special education classroom. The general education teacher typically does not have training in special education but receives consultative support from the special education teacher who provides indirect services (consultation to the teacher) and direct services (individualized instruction) to the student [102].
Nationally, the percentage of LD students now educated in mainstream settings has steady increased from approximately 23 percent in 1990 to approximately 59 percent in 2007. This trend is less marked but also true for other disability categories, and reflects federal and state policies that promote inclusion [103].
•Resource room or special education classroom placement with partial mainstreaming – Many elementary school children with LD receive instruction in the resource room or separate classroom for between 21 to 60 percent of their school days. In the resource room, remedial instruction is provided to small groups of four to eight children [102,104]. The resource room teacher usually has advanced training in the techniques of instruction and in the modifications required to individualize instruction for children with LD. Instruction in the resource room can focus on basic skills or learning strategies [105]. Remediation should be coordinated with the regular classroom teacher so that the student uses the skills acquired in the resource room to participate and learn successfully in the general education classroom [100].
•Self-contained classroom with minimal mainstreaming – Children with moderate or severe LD are usually served in a self-contained classroom, with 10 to 15 students, for more than 60 percent of the school day [106]. This setting enables more intensive individualized instruction, and students are able to receive more opportunities to practice required skills.
•Substantially separate placement – The student's education can be provided exclusively in a resource room or special education classroom, a private special education school, a residential facility, or a hospital setting. However, these settings often do not meet the criterion of LRE and would typically not be used for a student with a sole diagnosis of LD.
Although placement questions often are a source of discussion for parents and school personnel, a more important focus for discussion is the type of curriculum and services required by the student and the training of the staff required to provide the necessary curriculum and services. The type of instruction needed by the student and the quality of instruction delivered to the student are not determined by the placement [102,104,106,107]. Placement questions can be addressed only once the student's curricular and therapeutic needs have been determined. This issue is especially important for the adolescent with LD, as the curriculum provided has to address transition planning and may thus require service delivery outside a traditional school setting [108]. (See 'Transition planning' below.)
MANAGEMENT OF LD IN HIGH SCHOOL — As students enter secondary school, the focus of general education becomes more content driven; basic skills are no longer emphasized. Students with learning disabilities (LD) who are still mastering basic language, reading, writing, and math skills would be expected to have difficulty understanding higher-level classroom activities that are focused on content.
Lack of special education training among general education staff is more pronounced at the secondary school level. Inclusion in the general education classroom thus requires special attention to the student's capacity to identify, understand, and recall the information that is presented. If the student's education is to be meaningful, information may need to be presented at a slower pace, using alternative types of presentation (visual representations, such as pictures or movies, or more small-group, peer-mediated, or discussion-based presentation) (table 1) [109]. The student may also need to be permitted to use alternative means to demonstrate his or her knowledge (eg, writing by dictation, using word processors to help with word retrieval and spell checking, etc) [105,109]. It is also important to focus on strategy instruction, so that the student with LD learns how to elaborate upon ideas and construct knowledge independently (ie, as opposed to rote memorization of skills or information) [109-112]. (See 'Strategy instruction' above.)
Students with LD can complete a high school curriculum and can also attend college, in spite of their LD. That said, a significant portion of students with LD have difficulty accessing a general education curriculum at the secondary level. They may need to shift the focus of their education to acquiring life skills [113]. Specialized vocational-technical training or work-study programs should be considered [114-117] in conjunction with individual tutoring, instructional modifications such as reducing the work load while insisting on a higher number of correct responses, and strategy instruction [114-118]. Transition planning is an important component in determining the content of the student's curriculum and preparing the student for adult life, and it is discussed in the following section.
Transition planning — The high school curriculum should prepare students to cope successfully with the requirements of the postsecondary school or of employment [119]. In order to be successful, adolescents with LD require planning for the transition to their postsecondary life. Transition planning has traditionally focused on students with severe disabilities. However, students with LD also have significant limitations that affect their postschool success. Over one-third (35 percent) of students with LD drop out of school after the age of 14 years [120], which may indicate that a significant number of students with LD do not find their school experience to provide valuable knowledge or skills [121]. Although this statistic is concerning, there are also many students with LD who make the transition to postsecondary education. Appropriate and specific transition planning is thus needed by the adolescent with LD [122-124].
The Individuals with Disability Education Act (IDEA) requires secondary schools to initiate a plan for the transition from secondary school to postsecondary school (college degree programs, college certificate programs, or vocational training) or, depending on the student's interests and abilities, to employment [125]. This planning has to be initiated by the age of 15 years and continued throughout the rest of the student's public school career. School counselors are expected to participate in transition planning and to help to ensure that the skills needed for postsecondary education or employment are incorporated into the student's educational program, and to help choose appropriate postsecondary programs [126].
The IDEA lists the following components for transition plans [125,127]:
●Student invitation
●Measurable post-secondary goals
●Age-appropriate transition assessments
●Coordinated set of activities
●Outside agency invitation
●Annual individualized education program goals
●Transfer of rights at age of majority
Effective transition practices include the following components:
●Student invitation and student-focused planning – The student is actively involved in his or her own transition planning. This means that the student learns how to identify his or her own vocational interests and sets goals, and jointly monitors whether those goals are being reached. The student is expected to attend and participate in relevant planning meetings.
●Student personal development – The student learns about his or her own disability, learns how to address the limitations of the disability, and learns how to advocate for him- or herself to ensure maximum success. For example, the student is taught how to use strategies to help organize information, study effectively, and circumvent limitations in reading, writing, and/or math. In addition, the student is taught how to communicate about his or her disability with others (eg, administrators, employers, educators) and to advocate for his or her own needs. Finally, the student is taught about interpersonal communication in general, so that he or she can interact successfully with peers, accept feedback and criticism from educators or employers, and function successfully in a postsecondary school or work environment.
●Student vocational opportunities – In developing the skills listed above, the student is provided with vocational or work-site opportunities to acquire vocational skills and/or to generate educational goals to develop a vocation or trade. Enrollment in a regional vocational-technical school in the student's district or in a nearby district should be offered if desired [115].
●Student training in independent living – Systematic instruction in the basic concepts of maintaining a home, developing satisfactory personal and social relations, and participating in the community is just as important a component of transition planning to individuals with LD as it is to students with other disabilities. A variety of curricular models to achieve this goal, as well as the above goals, are listed in reference [128].
●Family involvement – Family involvement improves school attendance, increases higher-education attendance and assessment scores, improves student self-esteem and confidence, and reduces drop-out rates. Direct routine communication strategies, such as face-to-face conferences, telephone contact, open-house events, teacher notes, and classroom visits, improve educator and family interactions [124]. An important component of involving the family and the student is to help both make connections with community agencies, services, employers, etc.
●Interagency collaboration – In addition to the student- and family-focused aspects of transition described above, effective transition practices require the school to develop collaborative relationships with community agencies that offer work or vocational training opportunities and to develop a knowledge base of the colleges and postsecondary institutions and their services for students with LD. A variety of off-the-shelf curricular models for transition are available [129]. However, the school administration must be supportive of transition practices in general and provide the necessary leadership and vision for successful transition planning. This includes professional development in transition planning, creating collaborative relationships with community agencies and employers, etc [122-124]. The types of services described here are not available in a consistent manner across school districts or states [130].
SERVICES FOR LD IN COLLEGE — Students with learning disabilities (LD) are able to graduate from high school with a high school diploma. However, graduation requirements for students with LD may differ from those for general education students [131,132].
In the United States, approximately 6 percent of all undergraduates report having a disability; among these, 29 percent have an LD. This means that nearly 2 percent of all postsecondary students have an LD. Among undergraduate students, the average age of students with disabilities (type not specified) was 30 years, compared with 26 years among students without a disability [133].
Unlike public schools, colleges and universities are not required to identify or evaluate students for a disability, nor are they required to provide individualized special instruction. They are only required to provide "reasonable accommodations" to students with a documented disability. College students with disabilities must self-disclose their disability, must furnish documentation of their disability at personal expense, and must self-advocate to access those reasonable accommodations that may be available [134]. A detailed summary of the documentation requirement for college students is found in text of reference [135].
There are many services available for students with LD at the college level. Adolescents who are interested in pursuing a postsecondary education will need guidance in selecting appropriate college preparatory courses and will need information regarding the admissions policies of colleges, the special nonstandard conditions available for college entrance examinations, and the types of college programs available for students with LD [126]. Additional skills that are necessary for the transition to the postsecondary educational setting are listed in the table (table 5).
Services for students with LD at the college level can include program accommodations, such as a part-time schedule or modified course allowance, longer time to complete a program, ability to repeat classes without penalty, waiver of language requirements, and course substitution. Support services can include an individualized academic plan; tutoring; personal counseling; specific instructional learning strategies, such as training to improve memory and study skills; and training in the use of and access to adaptive technology, such as assistive listening devices or talking computers [136]. Students may also have access to alternative exam formats, readers and classroom note-takers, or textbooks on tape [133,137]. These accommodations and services are offered in a highly variable manner across colleges and universities.
OUTCOMES — Outcomes for individuals with learning disabilities (LD) are not clearly defined in the research literature. Several questions need clarification before overall adult status of students identified with LD will become clear. Most research addresses outcomes in terms of work performance and functionality. Outcomes research should focus on the employment status of individuals with LD, as well as their capacity to have friendships, create intimate relationships, and raise children, if this is their choice. Only a limited number of studies address all of these outcomes. In addition, many outcomes studies do not separate adults with LD from adults with other kinds of disabilities and only evaluate outcomes for the first few years following graduation from high school.
Reading, spelling, and math problems in individuals with LD persist into adulthood [138,139]. However, not all individuals with LD have difficulty in the larger task of living an adult life. After their high school education, individuals with LD are employed at the same rate as their nondisabled peers [140] but are less likely to have left home to live independently [141]; more likely to earn lower wages [142]; and more likely to have lower job satisfaction [143]. Adults with LD are less likely to obtain postsecondary education. Approximately 30 percent of individuals with LD pursue a postsecondary education, which is less than half of the population as a whole [140]. However, of those who pursue college training, wages and job satisfaction appear to be just as good as for their nondisabled peers [144,145].
Reframing of the meaning of their LD is an important predictor of success in adults with LD. Reframing involves recognizing, understanding, and accepting the LD. It also involves having a plan of action that includes the ability to answer employer questions about the impact of the LD on productivity and the individual's capacity for team work, as well as a consideration of non-work-related factors, such as the capacity to build friendships and intimacy, and the capacity to have a family [146].
INFORMATION FOR PATIENTS — UpToDate offers two types of patient education materials, "The Basics" and "Beyond the Basics." The Basics patient education pieces are written in plain language, at the 5th to 6th grade reading level, and they answer the four or five key questions a patient might have about a given condition. These articles are best for patients who want a general overview and who prefer short, easy-to-read materials. Beyond the Basics patient education pieces are longer, more sophisticated, and more detailed. These articles are written at the 10th to 12th grade reading level and are best for patients who want in-depth information and are comfortable with some medical jargon.
Here are the patient education articles that are relevant to this topic. We encourage you to print or email these topics to your patients. (You can also locate patient education articles on a variety of subjects by searching on "patient info" and the keyword[s] of interest.)
●Basics topic (see "Patient education: Learning disabilities (The Basics)")
SUMMARY AND RECOMMENDATIONS
●The management of the student with learning disability (LD) begins with quality instruction, even before the student is identified as having an LD. Quality instruction includes certain teacher practices, including spacing learning over time (ie, repetition of the same learning concept over time), combining verbal descriptions with graphics, connecting and integrating abstract and concrete representations of concepts, quizzing students to promote learning, helping students with time allocation, asking questions to develop greater awareness of the subject matter, and using preworked solutions for problem-solving exercises. (See 'Preventive measures' above.)
●For students who are not succeeding academically, "responsiveness to intervention" (RTI) services often are provided before the student is formally evaluated for LD. RTI is a legal term that applies to specialized academic and therapeutic services that are provided to a general education student to improve the student's success at school. The student's response to intervention can help distinguish learning failure related to inadequate instruction from learning failure related to specific LD (or another disability). The services provided are the same types of services that might be provided in a Section 504 Accommodation plan or in an Individualized Education program. (See "Specific learning disabilities in children: Evaluation", section on 'Diagnostic process' and 'Responsiveness to intervention services' above.)
●Components of quality instruction for children with LD include: explicit or direct instruction (ie, drill and practice) and strategy instruction (ie, instruction in the procedure or process used to approach learning). Quality instruction also applies to teacher behaviors, such as stating the learning objectives, having a clearly organized lesson plan, reviewing concepts multiple times, providing examples, and proceeding through material in small steps. (See 'Types of instruction' above.)
●Interventions for children with reading disability are discussed separately. (See "Reading difficulty in children: Interventions".)
●Instruction for children with writing disability should include explicit instruction in handwriting (transcription) accuracy, handwriting fluency, phonologic awareness and phonics (to help with spelling), writing fluency (the fluent production of correctly spelled words), and strategy instruction in language conventions (punctuation and grammar) and in writing text or compositions. (See 'Writing disability' above.)
●Instruction for children with math disability should include explicit and strategy instruction in number sense, math facts or math calculations, math fluency, math vocabulary, word problems, visual-spatial relationships, and organizing and planning. (See 'Specialized instruction in math' above.)
●The provision of quality services, interventions, and accommodations is preferable to grade retention or social promotion for children with specific LD. (See 'Grade retention and social promotion' above.)
●Planning for the transition to postsecondary school or employment is an important aspect of the management of LD during high school. (See 'Transition planning' above.)
●Reading, spelling, and math problems in individuals with LD persist into adulthood. After high school, individuals with LD are employed at the same rate as their nondisabled peers. Among those who attend college, wages and job satisfaction appear to be similar to those of their nondisabled peers. Those who do not attend college are less likely to have left home to live independently, more likely to earn lower wages, and more likely to have lower job satisfaction than their nondisabled peers. (See 'Outcomes' above.)
