Chaim appears to be lethargic in class. Lately, he has become disruptive, behaving in a silly fashion and making funny sounds. Upon investigation, it is discovered that he has serious reading deficits. Leah has been depressed and socially isolated in school. She cannot remember classroom material or her teachers' instructions. Evaluation reveals significant memory impairment. Moshe cannot seem to focus his attention on classroom activity for more than a minute or two. He frequently asks to go to the bathroom and can be found wandering the halls. The school psychologist says he has attention deficit hyperactivity disorder. Definition Whether you are aware of it or not, you know a child like Chaim, Leah and Moshe. They are among the approximately 20% of primary and secondary school students suffering-mostly in silence-from a learning disability.1 A learning disability is a selective, but serious weakness in a basic, yet complex function necessary for the acquisition of academic skills, that exists in a person of otherwise normal intelligence. Thus, Chaim may excel in number skills, visual analytical skills, and even his ability to use language; but he lags almost three years behind his classmates in his ability to decode words. The nature and severity of such disabilities vary and may affect language comprehension or expression, memory, attention, visual-spatial skills, perception, or other areas. They may invade a childís ability to listen, think, speak, read, write, spell, compute, or pay attention. Leah comprehends her class work easily but remembers little of it, and therefore regularly fails tests and accumulates little knowledge. A learning disability, as defined in this article, is not the result of emotional disturbance, mental retardation, physical handicap, or a situational disadvantage, such as family dysfunction. It is physiological and developmental in origin. Its causes can include genetic, prenatal, perinatal, postnatal, and central nervous system compromise. Generally speaking, a learning disability is no oneís fault; it is a nisayon-visited upon not only the child but also the entire family. Moshe's family knows this very well. He hardly ever picks up after himself; does not seem to hear when others call him, if he is engaged in an activity; interrupts others; and is generally impulsive. His mother is exhausted and at her wits' end. She believes she has failed as a parent. She does not understand that Moshe's problems are neurodevelopmental in nature. She believes them to be her fault, and in these feelings of failure and self-blame, her experience mirrors that of her son. Effects The effects of learning disabilities on school performance and the acquisition of academic skills can be profound. Though, as neurological deficits go, learning disabilities tend to be extremely subtle and even mild, they make normal learning in the traditional manner almost impossible without intervention in the form of adaptive learning techniques. This is because the unfathomable complexity of the human brain results in the everyday cognitive skills that we take for granted being comprised of many neurological steps, or functions. A deficit in any one of these steps will impair learning. A good example is word decoding, a skill that almost everyone takes for granted, yet is very vulnerable to disruption. Beyond the fundamental, sensory requirements of reading, such as visual acuity, there are very subtle, yet critical, brain functions involved. Reading requires, first of all, auditory and visual discrimination, i.e., the ability to differentiate between letters and sounds. The second requirement is sequential memory, both short- and long-term. This enables the child to recall letter sequences and their corresponding sounds. Then, smooth vocal-motor productions must take place. This means that the child must be able to imitate all speech sounds heard. Sound blending is also essential. The child must be able to combine letters and sounds to create words. As if this were not enough, the child must be able to orient in space such that our standard left-to-right can be followed. Then the crucial skill of sound-symbol correspondence recognition comes into play. The child must be capable of recording and reproducing the arbitrary sounds that correspond respectively to the arbitrary shapes we call "letters." Furthermore, the child must be capable of conditional learning, so that he understands letters do not have the same sounds in all contexts. It should be clear that a significant deficit in any one of these functions can sabotage the reading process, so that a learning disability results. In Chaimís case, we may discover that he is unable to blend sounds; as a result, though he can recognize letters and even reproduce their sounds, he cannot form their sequences into words. This small, subtle difference in Chaim's brain functions in comparison to other children's is enough in our culture to destroy most of his education. He cannot read. He cannot read in two languages. He is impaired in limudei kodesh (religious studies), as well as in limudei chol (secular studies). What most people fail to recognize, however, is that the most important effect of learning disabilities is not academic. It is emotional and interpersonal. A learning disabled child will feel he is a failure, as though he is to blame for the problem, even if he is fortunate enough to have been told that he is not, but especially if others have told him that he is. His self-esteem is profoundly affected, and he will prefer to suffer day after day of academic bewilderment in silence, rather than experience the shame of admitting, "I don't understand." Without awareness of the true nature of his problem, teachers and parents cannot offer the support and understanding, the patience and special attention that could carry him through school and peer relationships. The learning disabled child feels he is fundamentally different from other children and so does not belong. He may express his frustration in withdrawal and social isolation. He may be surly with peers and teachers; he may bully others or become the class clown, desperate for any kind of appreciation or attention. And so, among other problems in this population, we find disproportionate incidences of depression, delinquency, and substance abuse. It is also no secret that these problems are often a first step toward disengagement from Torah observance. Identification The alert and educated teacher or parent can often spot the child having learning problems. Concern should be noted whenever a child is observed habitually to be daydreaming, learning slowly, undisciplined, emotionally unsteady, disruptive, provocative, or lazy. A cardinal rule to remember is that laziness is not a natural state. The human child is naturally curious and given to intellectual growth. If a child is not growing, there is an impediment. He does not need to be tricked or threatened. He needs to be evaluated and helped. If the adult notices impaired memory, reasoning or speech; expressive difficulties; attentional problems; or hyperactivity, a professional should be consulted. If the child omits, mispronounces, or substitutes words while reading; can do some math operations but not others; has conceptual difficulties or sequencing problems or even very poor handwriting, an evaluation should be sought. Evaluation Children with any of the above problems require comprehensive psycho-educational evaluation. Such evaluation should include intellectual, educational, neurocognitive (cognitive brain function), and personality assessments. A less-than-comprehensive assessment leaves open the possibility that the evaluator has concluded his investigation prematurely and that an additional and possibly related disorder is contributing to the childís difficulties (a common phenomenon), but has been overlooked. Obviously, the long-term implications for the child of such an oversight could be enormous. At times, the evaluator may suggest adjunct evaluations by other specialists. These can include pediatric, neurological, speech and language, hearing, vision, or other examinations. What Can Be Done A good evaluation will provide not only an understanding of the child's problem but also recommendations for remediation. Often, tutoring is recommended. This may entail either regular or special tutoring focusing on particular areas of weakness. School-based interventions may be recommended. These could include modifications within the mainstream classroom; use of a resource room, the child receiving special tutoring during the school day; a special, self-contained classroom devoted to specialized instruction; behavior modifications; or a self-contained, special school. At home, parental or sibling tutoring may be suggested to support learning weaknesses. Often, behavior management is needed and can be supervised by a mental health professional. It should be remembered that accentuating the positive is very important for building the confidence that learning disabled youngsters so greatly need. It is essential to find a skill in which the child is strong (at least relative to his other skills) and to emphasize and help the child to develop it. This will aid in confidence building and satisfaction and may later lead to vocational options. Various therapies may be in order. Among these are individual psychotherapy (with parental guidance), family therapy, speech and/or language therapy, occupational therapy, and pharmacotherapy (medication). Outcomes What are the long-term effects of learning problems? Some children learn on their own to compensate for a disability by intensifying other functions to fill in the gaps. Without remediation, this task is an extremely lonely and burdensome one. In the case of attention deficit hyperactivity disorder, the child may leave much of the disorder behind, as he develops into adulthood. This, however, holds true for only a minority of learning disabilities. Others are lifelong deficits that require professional help of varying intensity and length to mitigate their effects. Therefore, the only reasonable and humane option for most youngsters is remediation of one of the sorts mentioned above. Without intervention, the effects are often devastating, severely and unnecessarily limiting the lives of otherwise intelligent people. Without the help of a reading specialist, Chaim may never be able to read a text or a newspaper. He may never have a driver's license. He may require that others read his job manuals to him, while he tries to conceal from others his embarrassing disability. He will likely be underemployed, because he will avoid jobs that require reading. Not having learned the strategies for supporting her weak memory skills, Leah may shrink from social contacts, embarrassed by her difficulties in recalling names or conversations. Her poor academic performance may severely impair her self-image, with chronic and debilitating depression the tragic outcome. Without diagnosis and treatment, Moshe can be expected to grow into the eccentric ne'er-do-well, unable to hold onto a job or a marriage, because he is too impulsive and inattentive to others' needs and sensitivities. Of course, the lifetime emotional toll of these painful problems can be devastating, much more devastating than the practical implications of the learning disabilities themselves. Too often, this is demonstrated for me when I explain to the family the nature and meaning of a learning disability I have diagnosed. Most often, this is the first time anyone has put all the pieces together, and the family responds with tears that are both bitter and sweet. Now that the secret is out, now that the blame has been expunged, parents and child can express the terrible misery of past, lonely struggles. Now, they can also weep with relief, knowing that the ghost that has haunted them has a shape and a name. Now help can be obtained.
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