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The Current Column:
An Overview of Learning Disabilities and Attention Disorders

by Jay Einhorn, Ph.D., May, 2000 The brain is the center of learning, and society (family, school, community, work) is the environment in which the person must learn. Learning disabilities exist when there is a significant discrepancy between some abilities and others within the individual which substantially affects his (or her) ability to learn and adapt successfully in his environment. Learning disabilities can affect language processing, mathematics processing, social processing, self processing, orientation for time and task, and organization of information. Learning disabilities are cognitive disorders. Attention disorders exist when the problem is not with cognitive processing as such, but when an impairment of ability to focus attention interrupts the flow of information to the cognitive processes of the mind. The person can learn if the information gets there, but the information is intermittent, interrupted, often insufficient for learning to take place adequately to the demand of the task. Both learning disabilities and attention disorders can involve many different parts and combinations of the complex processes of learning and attention in the brain. The two "halves" of the brain, which are actually the cerebral hemispheres at the top of the brain, process information differently. In most people, the left hemisphere is a sequential processor, maintaining an intense focus on one thing at a time in exact order. Because reading, writing, speaking and listening to speech are so dependent on letters and/or sounds and words being produced or recognized in a strict sequence, the left hemisphere is the one most involved in language processing. It may be involved in learning and following rule-based behavior, where the decision about what to do is based on an abstract model of what we are supposed to do in a pre-specified situation rather than spontaneously reaching a decision based on perception of a unique situation. It appears to be the location of the emotions of shame and silliness, the feelings associated with not fitting in socially. It also appears to be the seat of happiness. The right hemisphere is a relational perceiver, which sees how lots of things go together all at once. Because perception of social situations and relationships among objects require the balanced simultaneous recognition of multiple processes and relationships, the right hemisphere is most involved with interpersonal cognition. It is involved in understanding social situations. It appears to be the seat of empathy, the ability to understand how others are feeling without recourse to analysis. It is also the primary location of proprioception, the ability to be aware of one's internal state, whether physically or emotionally. Right-hemisphere predominant societies appear to be organized through ritual. The right hemisphere appears to be the location of feelings of fear, panic, anger, and joy. Some learning disabilities appear to be fairly clear impairments in one hemisphere or other. So do some attention disorders, because attention is primarily mediated through structures at the front of each hemisphere, and their reciprocal connections with arousing structures deep within the brain. Because there are lots of connections between the cerebral hemispheres, there can probably be situations when the interconnections become impaired or never develop properly. Accurate and useful perceptions of interactional dynamics or of complex interrelated processes over time, for example, are probably the products of a well-integrated functioning of both hemispheres operating at a fairly high level. Once this point is grasped it becomes easy to see how one could be stuck in the unbalanced functioning of one or the other hemisphere, and how that can lead to misunderstandings of situations and mistaken attempts to solve problems or take opportunities. Ideally, the hemisphere better suited for a particular task will predominate when such a task is presented. If one hemisphere's functioning tends to be much better than the other's, the person may try to approach all tasks in the style of that hemisphere. Everyone's brain is unique, with it's unique combination of relative strengths and relative weaknesses. There is probably a continuum of normal variation in efficacy between the hemispheres. For example, lawyers, as a group, may tend to approach all tasks as left hemisphere demand tasks, requiring analysis, while artists may tend to approach all tasks as right hemisphere tasks, demanding relational perception. When the normal continuum of hemispheric imbalance becomes too pronounced, because one hemisphere's cognitive functioning is more or less substantially and permanently below the other's, the person may be substantially impaired in a realm of life tasks. Or, parts of the functioning of either or both hemispheres that are responsible for such complex tasks as reading, may be impaired. Such cognitive impairments become functional impairments when a child or adult cannot learn a particular skill or set of skills which are important in his or her culture. This is a neuropsychological-anthropological perspective on learning disabilities. In schools, learning disabilities are usually defined as a substantial functional deficit in learning caused by a significant discrepancy between a child's ability and his (or her) achievement. Diagnostically, a learning disability shows up as a significant discrepancy within or between scores on tests of I.Q., achievement, and learning and memory. In our culture, learning disabilities have traditionally tended to be identified when children do not learn to read, write, or compute along with their peers in school. Thus, dyslexia (meaning a deficit in any form of language processing, but usually associated with reading or writing in common usage) or dyscalcula (mathematics learning disability) are well-established, if not always well diagnosed, forms of learning disabilities in American academic culture. Non verbal learning disabilities affecting the comprehension of written material which the child may be able to decode well, as well as social cognition, are becoming more frequently recognized and diagnosed. Because the proprioceptive or self-monitoring functions are located in the right hemisphere, and because self-perception is so influenced by how we see others reacting to our behavior, it seems likely that disorders of self perception having a cognitive basis might also accompany at least some non verbal learning deficits. There are a number of points along which a complex process such as language might go wrong. A reader may have problems decoding the written words, that is, sounding out the letters into words. He may have problems comprehending what he's read, for example, because he has difficulty sequencing the decoded words into meaningful sentences, or organizing a larger piece of writing into meaningful concepts. She may have problems with spoken language, with identifying words to express what she wants to say and putting them into a meaningful sequence for coherent oral expression. She may have problems with auditory processing of language, organizing and comprehending what is said to her. Or she may have problems with written language, and even here there can be more than one type of problem. For example, some people with L.D. for written language have problems spelling, others with the mechanics of written language, such as use of capitalization and punctuation, while still others have tremendous difficulty formulating what they want to write, although they may be normally, or even exceptionally, fluent in oral language. Attention deficit disorder (A.D.D.) refers to a number of different ways in which attention can be insufficient to support learning in certain situations. Unlike learning disabilities, there are no tests which specifically identify A.D.D. Every diagnosis in mental health is to some extent a clinical judgment call, but, compared with learning disabilities, for which there is a more or less general consensus about how to make the diagnosis--certain tests that one uses, certain kinds of results that indicate a learning disability-- for A.D.D. there is a more or less general consensus about what to look for, rather than how to look for it. An L.D. diagnosis is usually made by a psychologist or educational specialist with advanced diagnostic training, employing the same or similar tests from a more or less agreed universe of diagnostic instruments. A.D.D. can also be diagnosed by a psychologist after a lengthy evaluation including a full L.D. testing battery including neuropsychological tests and interviews with parents and teachers. But it can also be diagnosed by a psychiatrist after many sessions with a child and his parents and after interviews with teachers, by a psychologist or psychiatrist after a single interview with the child, or by a non-psychiatric physician based on a parent's report. Unlike L.D., there is no standard set of procedures for diagnosing A.D.D. Behavioral checklists are often used, which list various behaviors and ask the child and his teachers or parents to rate him on them independently of each another. As with language, so with attention: there are a number of different brain functions that go into attention, any of which can be operating more or less well or poorly. The Diagnostic and Statistical Manual, IV (DSM IV) currently recognizes two broad types of attention deficit disorder, hyperactive and inattentive, and a third, combined, type. Hyperactivity, once thought to be due to a child's being overly supplied with energy, is now widely thought to be due to a lack of properly functioning inhibitory processes. In order to focus our attention on one thing, we have to inhibit our attention from focusing on other things. If the inhibitory functions don't work well, we'll often be distracted. The hyperactive person's impulsivity is now thought to be due to insufficient inhibitory processes, and the reason that stimulants such as Ritilin, paradoxically, help hyperactive persons to be calmer and more focused is thought to be that the inhibitory tracts in the brain are undersupplied with neurotransmitter in hyperactive impulsive people, and they selectively consume the stimulant in order to function more effectively. There is a question about whether some distractible children and adults who don't fit in well at school or the office are really abnormal and suffer from a condition which needs medical correction, or whether they represent a normal variation in attentiveness which is just out of place in academic and office settings. Support for the latter position comes from the observations that many persons who have difficulty with impulsivity and distractibility in school become quite successful once they are able to get more control over their working lives in business, art, or a profession, and that many ADHD type persons are very sensitive to changes in the environment such as those which it is necessary for good hunters and trackers to perceive. Similarly, many children who have difficulty in school because of reading problems would not have been identified as having a problem for most of human history, since near-universal literacy is a very recent occurrence in human social evolution. Many dyslexics are gifted at seeing things whole, which can be shown in their ability to assemble and repair anything, to be excellent surgeons, or to be able to grasp the complex workings of financial organizations. Distractions not only exist in the outer world, they exist in the inner one as well. Thoughts, feelings, wishes, fantasies, dreams, anxieties, hopes, anger, sexual urges, creative problems that we're trying to solve, nascent artistic inspirations that occur at inconvenient times, preoccupations with relationship conflicts or goals, the entire stream of consciousness, cycles and swirls and presents ever-present stimuli to distract the attention from the outside world. Inattentive persons are distracted, not by external events, but by their internal processes. The stimulant medications that are often quite helpful for hyperactive/impulsive A.D.D. provide little or no help for the inattentive type, in general, which suggests that the different types of inhibition, of external and internal stimuli, are mediated through distinct brain networks. Another medication response of interest is that, for the more impulsive types, while stimulant medication helps reduce distractibility to external stimuli and sustain attention focus on tasks of learning, antidepressant medication seems to help raise the (often quite low) frustration threshold. These two different types of medication seem to facilitate different inhibitory functions, one against external perceptual distractions, the other against internal emotional distraction. Clearly, there are important therapeutic implications for working with clients with learning disabilities and/or attention deficit disorders. One is that the client's psychological biography, the history of his life and the development of his self, can't really be understood by the therapist or the client if there is an undiagnosed L.D. or A.D.D. The analogy is with a physical disability: the personality of the individual cannot be adequately understood for most therapeutic purposes without taking account of the disability, how others reacted to the person, and the meaning of the disability to the person, in the diagnostic impression. The fact that the L.D. or A.D.D. is invisible in itself and only becomes obvious through a careful analysis of behavior, creates an additional problem for the L.D. or A.D.D. person, who is often regarded as lazy, unmotivated, oppositional, or suffering from primary emotional problems, by well intentioned but uninformed authority figures, including teachers, therapists and parents. Thus, The therapist often has to be able to help her client with L.D./A.D.D. adjust to the present and plan for the future, so working out ways to capitalize on cognitive strengths and minimize or compensate for weaknesses becomes an important part of treatment. And the therapist may have to adjust his communication style in response to a particular client's L.D./A.D.D. For further information on the personal and psychotherapeutic implications of L.D. and A.D.D., see Carol Wren's and my Hanging By A Twig: Understanding and Counseling Adults with Learning Disabilities and A.D.D.