Part Three: ATTENTION, LIFESTYLES, AND LEARNING DISABILITIES
CHAPTER 7: Learning Disabilities: Neural Wiring Goes to School
"How can I teach these kids? They can't pay attention!" An insistent whine of complaint rises and gathers like a sinister haze over classrooms from preschool through college. Rather than serving as a warning, however, it has become a smoke screen for teachers and parents who belabor the young for failing to learn, and for politicians and professors who take potshots at the schools. While the adult community sanctimoniously bewails erosion of academic rigor and achievement, however, it perpetuates the practices that are shortening children's attention spans and rendering their brains unfit to engage in sustained verbal inquiry. Meanwhile, the schools, inundated with students who can't listen, remember, follow sequences of directions, read anything they consider "boring," or solve even elementary problems, have resorted to classifying increasing numbers of students as educationally sick.
"Learning disabilities," both formally diagnosed and unofficially suspected, are now blamed for a large proportion of learning casualties, from "underachievers" to school dropouts. The vast majority involve problems with skills of listening, language, and/or attention. Yet even "normal" students show increasing difficulty keeping their brains focused long enough to learn in traditional ways. Is something wrong with the kids? With their teachers? Or with the "fit" between the brains they bring to school and our expectations for them?
Attention, learning abilities, and learning disabilities are predicated on motivational and cognitive development in the brains of the learners. Each baby brain comes into the world uniquely fitted out for various forms of academic pursuit, but its pedagogical prognosis is largely determined by the ongoing mental traffic that trains it how to think and learn. For children, habits of the mind soon become structures of the brain -- and they absorb their habits, either directly or indirectly -- from the adult culture that surrounds them. For many, the habits of the mind that they take with them to school predispose them for trouble.
To understand the growing number of educational casualties today, we must face some often unrecognized realities about the brain-culture partnership. Particularly troublesome are some new factors that fuel the anomalous category of "learning disability," for which children are treated with educational prescriptions, and its frequent companion, "attention deficit disorder," for which many receive brain-altering drugs. Here are some questions that we need to address in these three chapters:
1. What is the real meaning of the term "learning disability" and why are there now so many in our schools?
2. Do children inherit learning problems -- or are they caused by the environments in which they grow up?
3. What is an "attention deficit"? Why do increasing numbers of children seem to have them?
4. Should children receive drugs because they can't pay attention in school?
5. What are the physical foundations of attention and how can they be damaged by toxic and noisy environments or sedentary lifestyles?
6. What is the role of the home in preventing attention and learning problems?
7. What does attention have to do with our current crisis in "problem solving"?
A RISING TIDE OF DISABILITY
The problem of getting students to sit still, pay attention in class, and reflect thoughtfully on the task at hand figures prominently, along with reading difficulty, in an astonishing "epidemic" of "learning disability" in otherwise able children. Since the 1970s when the label, popularly referred to as "LD," became an accepted designation for problems not attributed to intelligence, physical, or emotional status, this loosely defined diagnostic category has grown geometrically. It now includes some children who might previously have been categorized as mentally deficient or emotionally disturbed as well as a large number who are having trouble in school for reasons that are often unclear.
Many students with specific difficulties in learning never make it into the maze of psycho-educational testing that leads to official diagnosis, but the number who do is rapidly becoming unmanageable. In the United States from 1976 to 1985, there was a 135% jump in diagnosed cases of learning disability from 796,596 to 1,868,447. [1] By 1988, Dr. Margaret C. Wang, a noted learning-disability educator, observed that up to 15,000 children nationwide per week were being referred for assessment. She warned that a "second system" of children with special learning needs was developing within the regular educational system. [2] This "second system," incidentally, is not an economic dumping ground; the diagnosis of "learning disability" has been a predominantly middle-class phenomenon.
Dr. Wang points out that up to 80% of American schoolchildren could now be diagnosed as learning disabled by one or more of the methods used, which may vary even between adjacent school districts. It is impossible to determine how much of the avalanche of new referrals is attributable to teachers' growing reliance on this method of extruding troublesome youngsters from classrooms. The only clear fact that can be derived from these statistics is that there is a serious misfit between large numbers of children and their schools.
"ATTENTION DEFICIT DISORDER"
In a great proportion of diagnosed cases, a subcategory of learning disability variously named "hyperactivity" or, more currently, "attention deficit disorder -- with or without hyperactivity" is implicated, even when the primary difficulty lies in a specific academic territory such as reading. All "attention deficit disorder" cases have trouble focusing and maintaining attention appropriately; the term "hyperactivity" implies that the child's body, as well as mind, is bouncing off walls. One of the most invariable school symptoms of any form of attention disorder is difficulty listening attentively and remembering what the teacher says.
The exact relationship between "ADHD" (attention deficit with or without hyperactivity disorder) and other forms of "LD" is unclear, but experts estimate a 50% to 90% overlap between the two categories. [3] The impossibility of finding clear data is a frustrating testimony to the imprecision of educational diagnosis, but unquestionably, one of the main reasons the "LD" category is growing so large is because of a dramatic increase in the number of children with "attention disorders."
Flaky Kids and Pharmaceuticals
Currently in the United States, anywhere from one and one-half million to four and one-half million schoolchildren, mainly boys, bear the official diagnosis of ADHD. Incredibly, in some classrooms, more than 50% of students have been diagnosed as hyperactive, a fact rendered less surprising by a recent report that pointed out that one-third of all American boys meet some of the criteria. [4] Teachers say, however, that the identified cases represent only the most serious and unmanageable ones in an increasingly inattentive population of students. Girls are also more inattentive these days, but partially because they do not tend to cut up as much in class, they are referred for diagnosis less often.
In other parts of the world the incidence of ADHD is seen as being much lower, but rising numbers of cases have recently been reported from countries as widely separated as Finland and the People's Republic of China, to name just two examples. [5, 6] A West German pediatrician specializing in the disorder recently published a study of a thousand children whom he had treated for attention disorders, many from upper-middle-class families. [7]
One controversial aspect of this problem is an increasing use of stimulant drugs to enable these children's brains to behave more attentively. As of this writing, an estimated 6% of American schoolchildren are being given a prescription drug, most commonly Ritalin, to render them sufficiently manageable to do their work in school. In some communities, where certain pediatricians have "specialized" in "hyperactivity"/attention deficits, the percentage is much higher. Some parents are also choosing to augment the prescribed daily dosage to counteract the drug's "rebound" effect and enable their offspring to manage themselves acceptably at home. A 1988 article in Education Week entitled "Debate Grows on Classroom's 'Magic Pill'" pointed out that the production of Ritalin in the United States doubled between 1985 and 1987. [8] In the next chapter we will take an in-depth look at this whole issue. For now, let us explore the more general range of "learning disabilities."
"LD": MISFITTED BRAINS
Different Wiring Systems
I find that parents, and even teachers, are often confused by the term "learning disability." Contrary to what many have been led to believe, most children diagnosed as "LD" have not suffered any identifiable kind of brain "damage" either before or after birth. Moreover, they may be highly intelligent. Some nervous systems come into the world jumpy, clumsy, or otherwise ill-equipped for learning, but many children who wear the label "LD" do not have anything noticeably the matter with them. Even in neurological examination they may seem to be essentially "normal" children who function well in most settings -- except for the classroom. It is especially hard for adults to understand why such a child should have difficulty with specific aspects of learning such as reading, math, memory, and paying attention.
Also contrary to popular belief, once a diagnosis is arrived at, professionals cannot simply "fix" the child just because they have put a label on the problem. Unfortunately, understanding of the vagaries of the learning brain is so tenuous that most treatment is still based more on "what works" than on a clear-cut neurological rationale.
The main reason diagnosis and treatment are so difficult is that all kids' brains are unique -- the LD child's is just too unique for the school to handle. Even though all our brains are cut from the "Homo sapiens" template, each responds individually to different types of tasks, and each is potentially better at making synaptic connections for some kinds of learning than for others. The basic neuronal wiring diagram is determined both by the genetic blueprint and the environment in the womb; the postnatal environment helps determine how the connections get hooked up -- according to how the child uses them. By definition, a specific "learning disability" occurs only when the child takes that special brain into a learning situation, batters his neuron assemblies against a certain kind of demand -- and fails. In an extreme example, let us imagine that a child with a brain specifically ill-equipped for reading went to school in a society where all information was conveyed pictorially or by storytelling. The "learning disability" would never materialize!
Even in preschool years, a child's mental life and motivation interact with basic brain structure to shape specific talents for learning. By the time children enter school, each has a singular pattern of abilities, disabilities, and interests. Some children's patterns fit neatly into the classroom; others' talents show up more clearly on the playground, in the art or music room, in interpersonal politics, or when someone needs a friend. But these skills don't earn stars on the spelling chart -- or many A's on the report card.
Some LD youngsters have wiring systems that must struggle harder with learning because of general difficulty with one or several of the following: memory, coordination of hands and eyes, rapid comprehension of new situations, language, visual-spatial reasoning, abstract thinking, or ability to focus attention quickly and appropriately. Even a problem that appears to be quite generalized, however, such as a memory problem, may actually show up only in particular (task specific) types of learning situations. Many times, when students come to me to complain about a "memory problem," it turns out they are really talking about verbal memory for things they read or hear; they may be terrific at remembering where Dad mislaid his car keys or how to put a Rubik's Cube together. The real "problem" is that brain systems are wired up better for some types of memory than for others, and the weak ones don't show up until they are called on to perform.
Sometimes I reflect ruefully, when I watch children trundled off to the "resource room" for tutoring in reading or spelling, that I, too, might have been LD. Like many who later chose teaching as a career, I was lucky that my brain's native abilities and my language-rich environment combined to fit me out quite nicely for my first-grade classroom. If at age six, however, I had suddenly been dropped into a society of visual artists, with a curriculum that consisted of drawing pictures and designing architectural blueprints instead of reading and spelling, I would shortly have been consigned to the "disabled" list. Wallowing messily in failed expectations, I would have waited for the weekly visit of the special reading teacher and my brief taste of success -- that is, if the verbal "frills" hadn't already been cut from the school budget. Many children who face the opposite problem in our language-centered schools pine for the "frills" of art or music class but have little opportunity to be recognized for their talents. Are these students' brains "damaged" -- or just disabled relative to that particular curriculum?
Should we change the curriculum? Must we alter teaching methods and the pace of instruction to accommodate growing numbers of "different" brains? These questions are increasingly being forced on teachers, who, even in the "best" schools, are discovering that giving students more of the usual types of instruction does not backfill the gaps. Meanwhile, the society clamors for higher standards -- and our graduates can't compete in world markets.
Perhaps the American popular culture ought to take a hard look at its own curriculum. Because the kind of "coaching" provided by early environments has so much to do with a child's adjustment to school learning, everyone has an obligation to our children -- and to their future teachers -- to provide them with experiences likely to build the skills they will need in the classroom. This does not mean that parents should prepare lesson plans for infants, expect preschoolers to read, or drill kids on math facts when they are in their high chairs. It does mean someone must help them learn to listen, direct their own thinking, and use language effectively. I have already described the erosion of language stimulation for many children today; now let us explore more fully the ways in which environments are teaching them not to pay attention. These two problems are closely related and may account for much of this mysterious "epidemic" we are now experiencing.
Listening Skills and Learning Disabilities
By far the majority of learning disability referrals include difficulty listening to, understanding, or expressing verbal material, reading, writing, and spelling. These skills all rest on an underlying complex of "auditory processing abilities" and are mediated by language areas in the brain's left hemisphere. They include abilities to:
• listen carefully to the order of sounds in words or of words in sentences
• discriminate between similar sounds (e.g., sh and ch)
• remember things that have just been heard ("short-term auditory memory")
Problems with the above do not stem mainly from defects in the ears, but from the brain's processing centers. The sounds may get in, but they become scrambled or lost before they can be analyzed, understood, and remembered. One of the most prevalent symptoms of such problems is difficulty in recalling spoken directions. For example:
Parent: "Please go upstairs, get the soap out of the closet, and bring it to the laundry room."
Child: "Huh?"
Children with poor auditory skills -- whatever the reason -- have a difficult time learning to read, spelling accurately, remembering what they read long enough to understand it, or retaining the internal sound of a sentence they want to write down. They tend to tune out during class discussions and when the teacher lectures or gives directions. They respond much better to visual input, particularly if it is in pictorial rather than written form.
To compound the difficulty, children who do not have to listen can easily develop habits to avoid exercising (and thus building) these important auditory-processing connections. The very act of remembering lays down physical tracks in the brain, but children can quite easily avoid having to build these systems. When a teacher gives directions, they watch her for clues or look around to see what everyone else is doing (now that so many seem to have this problem, sometimes no one knows!). They say "Huh?" enough times to make frazzled parents either show them or do it themselves. When they don't hear the homework assignment in class, they call a friend. In reading they rely heavily on pictures in the text. Most children get the message more from the pictures than from "talk" when they watch TV, so extended viewing -- particularly in early years when these brain connections are forming -- compounds the problem. No wonder, when they have to read longer stories, math word problems, history books, etc., they can't hold the sound of the words inside their own heads long enough to understand what they're reading! Their brains have simply not been trained to understand and retain discourse.
What causes the basic weakness? Research suggests this type of problem may tend to run in some families. Nowadays, however, when most children's listening experiences are limited or attached to pictures, it is difficult to sort out who inherited the problem and who "caught" it from the environment. Whatever the cause, studies have shown that early experience with careful, analytic listening can dramatically improve auditory processing, listening comprehension, and in turn, reading ability -- even in children with an inherited weakness. [9]
HEREDITY, ENVIRONMENT, AND "EXCEPTIONAL BRAINS"
Scientists are trying to get more specific about how nature and nurture affect patterns of learning ability. They have found that "exceptionality" (such as musical, mathematical, or linguistic talent, as well as some categories of learning disability) may be related to inherited differences in the way brains are constructed. Nevertheless, the effects of environments created by family members with particular interests can't be discounted, say Drs. Lorraine Obler and Deborah Fine in their fascinating book The Exceptional Brain. "Stating that a talent or disability is biologically or genetically based does not mean that it will necessarily develop or fail to develop regardless of the conditions under which a child grows up. Certain environmental factors are crucial for the manifestation of talent as they are for the manifestation of disability." [10]
Genes, Dyslexia, and the Fetal Brain
It is difficult and highly technical work to sort out the respective effects of genes and family habits, agrees Dr. Bruce Pennington of the University of Colorado. Dr. Pennington is director of a large study searching for specific genes by which language, reading, and learning disabilities can be transmitted from parent to child. Just because many members of a family have a certain trait, he says, we cannot assume it is necessarily genetic. After all, poor table manners can run in families!" [11] Likewise, parents who enjoy reading and conversation will tend to surround their children with a literacy-rich environment and extensive listening experiences, and vice versa.
Nevertheless, Pennington's research, the largest family learning-disability study ever conducted, has confirmed that some specific types of learning difficulties, including language disorders such as stuttering, speech, and some reading problems, are genetically influenced. Members of these families, interestingly enough, are often distinguished by talents in other areas. As researchers work to clarify definitions and probable causes, they are uncovering some fascinating clues about why this might be true.
The term "dyslexia" has often been used as a garbage can for any kind of problem with reading. Current research, however, has limited the use of the term to describe a brain-based disorder in putting together the sight and sound of printed language in reading, spelling, and writing (e.g., looking at a letter and saying its sound; remembering how to write said). Dyslexic children, who compose only one special segment of the entire LD population, may also have difficulty with some aspects of oral language, such as coming up quickly with the word they want to say or getting the order of the sounds and syllables straight. Because they tend to mix up the order of letters and words when they read (and sometimes the order of numerals when they do arithmetic), people used to think the problem was in their eyes. Now it is suspected that the culprits really are deficits in left-hemisphere systems responsible for analyzing and arranging things in sequential order and linking sound with written symbol.
Even with their genetically "different" brains, dyslexic children who come from homes where they have been exposed to books and good examples of language often learn to read reasonably well. Although their spelling is often "atrocious," these youngsters may escape diagnosis as they learn to compensate for or cover up their difficulties. They also prove that "disability" is a relative term, as they are often talented in more predominantly right-hemisphere skills, such as visual arts, mathematical reasoning, music, mechanical aptitude. [12]
Attention problems in school frequently accompany dyslexia, but dyslexics often have excellent visual attention for details of things they see (other than printed words!), and they can spend long hours in activities such as working on an engine or a design. They are youngsters who might be academic stars in a culture with a different set of intellectual priorities.
How are these brains different? Studies using new computerized pictures of brain areas in action show that dyslexic children seem to use different neural systems for reading than do "normal" readers. [13] A second line of evidence suggests that this mix-up takes place because certain brain areas developed differently before birth. Because the young brain is so plastic, it manages to reorganize itself around reading, but academic skills still suffer to some degree.
"A Terrible-Looking Brain"
Not long ago, the late Dr. Norman Geshwind and his colleague Dr. Albert Galaburda, of Harvard University, began intensive work on the brains of several dyslexics who had willed them for study. All of these brains differed in particular ways from the "normal" pattern of cell organization, especially in one general language area of the left hemisphere. Microscopic analysis pinpointed the origin of the differences at a certain period of prenatal cell migration. Instead of finding their intended homes, groups of neurons ended up in peculiar places and arrangements. Moreover, areas in the right hemisphere -- the ones, in fact, that would probably underlie visual, mechanical, or other creative abilities -- were proportionately larger in these people. [14]
Given the growing evidence that dyslexia tends to run in families and to be more evident in males, Dr. Geshwind decided to interview families of dyslexics. When he uncovered repeated prevalence of left-handed relatives and autoimmune, or allergic, disease, he developed a theory. He speculated that imbalances of hormones or antibodies secreted by the mother at different times during pregnancy might subtly rearrange the infant's brain in ways that would make it less adept at reading and language, more talented in visual-spatial skills, and more likely to be left-handed. [15, 16]
No final answers are yet available, but this research is being continued by Dr. Albert Galaburda. Until more is known, these studies provide powerful evidence that even though baby brains are born with differences, they can eventually learn to accomplish a complex learning task (in this case, reading) with brain systems different -- and perhaps geographically far removed -- from the ones best suited for the job. The scientists working on these projects agree that the way dyslexics -- or anyone else -- use their brains is a critical factor in modifying them.
I had an opportunity to chat with Dr. Galaburda after a recent speech in which he emphasized "the Darwinian-like interaction" between the environment and the growing brain. Genes provide the environment with "a range of structures to choose from," he explained, "and the environment chooses from this range of possibilities. The structure of your brain determines that you can dance, but it doesn't permit you to fly," he said, smiling. ''There are some things the genes just don't permit. But on the other hand, the brain is not prewired to act just one way; instead it gives the environment certain flexibility in selection. I think even if children have not quite the best wiring diagram for something, you can make it look better or less well depending on the environment. [17]
"Different kinds of environmental factors, from chemicals to societal pressures . . . are potentially capable of resulting in abnormal brain interactions," explained Dr. Galaburda. On the other hand, his studies of dyslexic brains have reminded him that we should never underestimate the ability of the brain, given the right kind of support, to compensate for innate difficulties. "If you change the brain [before birth] you probably change the range of possibilities that are available to this brain in some sense, but the range of possibilities is still very great. One of our dyslexics was a very distinguished, famous, brilliant psychologist and she had a terrible-looking brain!" [18]
The Flip Side of Dyslexia: Nonverbal Learning Disorders
Scientists are hot on the trail of brain differences that lie behind another difficulty, termed "nonverbal learning disorder," which seems to stem from the opposite problem: insufficient right-hemisphere power.
People with right-hemisphere disabilities may be quite competent at linear, sequential skills like spelling, reading out loud, or doing basic math equations, but have trouble when they must comprehend abstract ideas, relate to people socially, or reason in a visual-spatial format (e. g., maps, charts, three-dimensional puzzles, architectural drawings). They have trouble understanding the relationship of their bodies in space or the ideas in literature or social studies. They almost invariably run afoul of more advanced math courses. Their primary difficulty is one of seeing the "whole picture" of a situation: sizing up meaning when they read or when they deal with others, for example. They may have trouble interpreting the emotional quality of people's facial expressions and do or say inappropriate things in social situations. [19]
[A Cautionary Note: Most of us lean toward one "style" or another but are still well within the normal range; just because any of these descriptions sound like someone you know does not mean they have a brain disability, just that they are at a different point on a continuum than someone else. The fact that we all have unique patterns of talents keeps us supplied with people who want to be proofreaders as well as those who prefer architectural design.]
Serious cases of nonverbal learning disorder, in which the individual's abilities are obviously affected, are just now receiving professional attention. Little is known about causes or treatment, but researchers suggest early intervention to help the brain develop connections for manipulating the physical world and understanding other people's reactions and the principles behind ideas.
Children who show this type of learning profile may not look "disabled" in early grades and are often, in fact, viewed as quite advanced because of large vocabulary, facility on the computer, early reading of words, and good math computation skills. The tipoff is that they tend to pursue linear kinds of learning, like computer math or spelling drills, as obsessively as they avoid such visual-spatial challenges as video games, team sports, or mechanical puzzles. [20] Since the child's family may share some of the same characteristics, manual and interpersonal abilities may not have high priority at home.
Nonverbal learning disorders and dyslexia are just two of the many conditions that get lumped under the term "LD" (and which may or may not include "attention deficit" problems), but they are among the major ones for which specific, and possibly inherited, brain differences have been suggested. No one knows how many "learning disabilities" are caused by environments that interact with more "normal" brain patterns to make children unprepared for school learning. Most experts agree, however, that this number is probably growing. Because the types of technology needed to look, literally, at the learning brain are only now being developed and are expensive, it will be a long time before we fully understand the normal learning process, let alone all its variations. A few scientists have already begun the quest.
Looking Inside the Brain
At Michigan State University, Dr. E. James Potchen, chairman of the Department of Radiology, works at the forefront of these efforts. He directs a project in which magnetic resonance imaging, a method of seeing the working brain in "exquisite detail," as he says, is being used to probe the relationship of brain structure and learning disability.
Dr. Potchen has looked at 18,000 brains, and says that "we are all abnormal because all brains are so different. It's amazing we do as well as we do." Having brain differences should not necessarily be viewed as having a disease, he maintains, and there can be tremendous changes in the architecture of the brain from learning. He guesses the child's brain is always in the process of being rewired.
Dr. Potchen tells of both animal and human brains that have restructured themselves significantly on the basis of learning experiences. Some types of birds even develop new neurons when they learn to sing. In a human experiment he showed pictures of a stick figure to doctors and artists while their brain activity was being scanned. Different areas of the cortex would "light up" depending on the individual's profession. The artists, looking at the drawing, showed brain patterns indicating greater complexity of association and understanding.
This curious researcher has also been examining his own brain every four years to look for changes. "I haven't yet got to the point where I can see that if my golf swing got better, it would change my brain, but that may be coming -- especially for children." [21]
FITTING BRAINS TO LEARNING -- AND FITTING LEARNING TO BRAINS
Research like Dr. Potchen's has obvious promise for educators, but we are still a long way from being able to plan teaching on the basis of brain scans. In the meanwhile, this research should certainly sensitize us to the fact that learning environments -- at home or school -- can partially rearrange neural wiring diagrams. They can help the child overcome or compensate for innate differences or predispose to problems. In our schools, children who come with deficits in auditory attention and language processing are headed for trouble.
As I learn more about the wide variety of ways in which students' brains may differ from each other's -- and from my own -- I become increasingly aware of the importance of the "fit" between their brains' particular contours and the learning environment into which they have been injected. Now, when I walk into a classroom of twenty students, be they four- or forty-year-olds, I remind myself that I am trying to teach twenty individual brains that are probably as different in their learning patterns as my students' faces are in appearance. As a teacher, I must accept the fact that their level of success -- and thus their motivation -- will be directly related to the accommodation we mutually achieve between the subject matter and their particular pattern of abilities. I must encourage them to push themselves a little harder on things that do not come so easily, but I must also accept the necessity of supporting and working to develop each student's potential. Even with twenty students, which is fewer than the number found in most classrooms, this job requires skill, patience, and a lot of hard work.
If we could, as teachers, fill this awesome assignment, I venture to say both the number of "learning disabilities" and the dropout rate would decline precipitously. Our job is getting increasingly difficult, however, because we seem to be standing in the way of an avalanche of brains that are misfitted to our educational objectives. A teacher can easily become engulfed trying to reconcile administrators' demands for "achievement" with today's language and attention patterns. Unless the adult community decides to help us wrap these growing brains in the mental garments of language, reflection, and thought, I fear we will continue to see increasing numbers of children categorized as "educationally sick."