Academic problems are some of the most frequent reasons for obtaining a neuropsychological evaluation.  Problems in school are due to a variety of factors including poor attention, behavior problems, medical or neurological illness or disorder, and bona fide Learning Disorders.  The purpose of the neuropsychological evaluation is to determine the cause of the academic problems so that proper services and treatment can be put in place.

Learning Disorders, which are estimated to impact approximately 7% of school-age children, are diagnosed when an individual's ability in reading, writing or math skills is below what would be expected based on age and/or grade level and interfere significantly with the individual’s functioning in school or in activities of daily living where reading, writing or math may be necessary.  Learning disorders are typically divided into three subtypes, according to the fourth edition of the Diagnostic and Statistical Manual of Mental Disorders (DSM-IV-TR; American Psychiatric Association, 2000).  These are: 1) Reading Disorder: 2) Mathematics Disorder; & 3) Disorder of Written Expression.

Reading Disorder (RD) / Dyslexia

It is estimated that approximately 5% of school children have a Reading Disorder or dyslexia and these children account for approximately half of the special education population.  Genes are presumed to underlie at least some aspects of reading disorders.  For instance, many children who struggle with reading have parents or siblings who also struggle.  However, it is likely that multiple chromosomes are involved.  Other causes of reading problems include poor educational opportunities and traumatic brain injuries.  When a reading disorder is caused by trauma to the brain, the disorder is referred to as alexia. 

When an individual presents with reading difficulties, problems are usually reported with decoding and/or comprehension.  Frequent complaints include having to read and re-read text multiple times, forgetting what one has read, reading very slowly or substituting/guessing words based on context. For an individual to develop into an effective reader, three components are essential: phonological processes, orthographic processes and phonological fluency.

Children who have difficulty with phonological processing are often have auditory processing deficits that result in poor phonological awareness.  These children (and adults) have normal hearing, based on audiological examination, but may have been prone to ear infections and required myringotomy tubes.   In addition, language issues may also be prominent.  For example, as infants, the children may have experienced delays in language development.  Articulation issues may have been noted (e.g., pronouncing the l sound as w) or the child may present with problems in receptive language (i.e., language comprehension) and expressive language (i.e., the ability to express oneself using language).

Children with the phonological subtype of reading disorder have a poor understanding of the sound-symbol relationship, which  refers to the their understanding of the sounds of which a particular language is comprised and the letters used to represent the sounds (It is interesting note that children who struggle in their mother tongue, also struggle when attempting to learn a foreign language). As a consequence, their phonological awareness (i.e., the understanding of the sounds and ability to manipulate them) is impaired.  Intact phonological awareness is essential for the decoding process – sounding out the words.  When phonological awareness is impaired, children often rely on compensatory strategies, such as sight words and guessing at words based on their configuration or the context in which they are located. This results in poor comprehension of written material, particularly in higher grades.

Children with deficits in orthographic processes experience problems with graphemes & morphemes.  Morphemes are the smallest units of sound in a language that convey meaning.  For example, the ending ed is most frequently used to denote the past tense of a word (e.g., climbed is the past tense of climb).  Graphemes are the written versions of morphemes.  In this type of RD, children have little difficulty with words that make phonemic sense (e.g., words such as to that sound like they are spelled), but have trouble with words that are irregular in some way (e.g., two may be read as t-w-ah).  Their reading tends to be slow and laborious.  This is the type of RD where words and letter appear to move, letters are misidentified (e.g., confusion of b,d, p, q, s, & z) or transposed (i.e., letters within a word are switched), or letters in the middle of words are missed during reading.

Fluent reading refers to reading that is smooth, rapid, and automatic.  Children who struggle with this component of reading tend to have adequate decoding skills (i.e., both the phonological and orthographic processes may be age-appropriate).  In contrast, these children read slowly and make many spelling errors.  In addition, the children report forgetting what they have read.  Forgetting is due to the fact that working memory only has a short amount of time to process information.  When processing speed is poor, at least a portion of the information obtained from reading text is likely to be lost.  This type of RD is more likely to be associated with deficits in executive functions and is commonly found in children with the inattentive type of ADHD.

The role of the neuropsychological evaluation is to determine why the child or adult is struggling with reading, specifically, looking to determine which of the aspect or aspects of reading process (e.g., phonological processes, orthographic processes, or fluency) is/are not operating properly.  By providing a detailed assessment, this enables an individualized program to be developed based on the child's individual needs.