36 Diagnostic Evaluations: Academic Development and Specific Learning Disorders

General recommendations for considering a diagnosis of a specific learning disorder

It is possible for blind and low vision students to have a specific learning disorder. To diagnose a specific learning disorder using the DSM-5-TR, vision must not be the primary cause of academic difficulty. Vision can be a contributing factor, just not the primary cause of the difficulty. It is possible that both the vision and learning issues may be related to the same underlying condition (e.g., a genetic or neurological disorder).

Evaluation for a specific learning disorder will involve looking at various data points (i.e., not just a single subtest) and integrating information from multiple sources. This should include curricular-based measurement, a review of work samples, and interviews with the student’s team (Layton & Lock, 2001). For braille learners, the expected progression of numeracy, reading, and writing, are not the same as the progression of the same skills in sighted peers. When evaluating braille readers, speak with the student’s TVI to find out if the student is on the expected developmental track.

To be comprehensive, assess the following cognitive and processing areas based on the referral. Assess to the extent possible that can be done validly given the student’s level of access:

• Verbal intelligence: lexical knowledge, language development, listening abilities, general information
• Fluid reasoning: induction, quantitative reasoning, deductive reasoning
• Short-term memory: working memory, memory span, recognition
• Long-term memory: meaningful memory, free recall, associative memory, ideational fluency
• Auditory processing: phonetic coding, sound discrimination, auditory memory
• Orthographic processing
• Executive functioning: attention, self-control, organization

Consider using a cross-battery method of assessment to tap into the various areas as no one test is likely to have subtests that can be made accessible in all construct areas. Use two or more narrow abilities to represent the broad ability domains. Use two or more subtests that measure the same or similar narrow ability to represent the narrow ability domain. When a student presents with low performance on one subtest, it is best to administer another subtest that assesses the same or similar narrow ability.

In addition, consider how executive functioning may be impacting learning progress and performance.

In order to diagnose a specific learning disorder, the student must have had appropriate instruction by qualified personnel (e.g., taught with an appropriately leveled curriculum that is accessible, provided instruction for sufficient duration and frequency, etc.).

It is important to start with the student’s visual condition and its educational implications. Then, it is important to have a thorough understanding of the student’s functional use of vision. Review adaptations, accommodations, and instructional practices, and how these were successful or unsuccessful. Response to intervention must be carefully documented. Remember, blind and low vision children generally learn to read in the same manner as their sighted peers but require much more intensive and direct instruction.

Limited appropriate instruction, changes in learning media over time, and limited integrated use of alternative media across classrooms can complicate differential diagnosis.

To determine that blindness or low vision is not the “primary cause” of academic difficulties, consider the following.

1. Determine whether appropriate interventions and accommodations for vision loss were provided across educational settings.
2. Ensure testing follows best practice guidelines for the evaluation of blind and low vision students.
3. Determine whether attendance and service delivery impacted the fidelity of IEP implementation.

If the IEP was implemented with fidelity (i.e., appropriately providing for the needs stemming from vision loss) and there is limited progress despite adequate academic instruction and intervention, the visual impairment does not fully explain the student’s academic difficulties. Given this profile, a diagnosis of a specific learning disorder may be appropriate for a blind or low vision student who is performing substantially below the expected level in academics.

Specific learning disorder and visual impairment reflection points

When academic skills are not developing as expected, consider the following.

• Has the student’s visual impairment impacted their vocabulary and concept development, secondarily impacting their reading and writing skills?
• Could early reading delays be related to reduced early learning opportunities? In the early years, children with significant visual impairments will have less incidental exposure to print in their environment, unless they have had very explicit support and intervention. Sighted children will incidentally learn that printed symbols represent words, whereas children with an early, significant visual impairment will need this explicitly taught.
• Has the student had access to instruction using appropriate materials and adaptations? Were the recommendations from the TVI’s functional vision assessment (FVA) and learning media assessment (LMA) implemented consistently and with fidelity?
• For braille readers, are there tactile (sensory) or motor challenges that are interfering with learning?
• Was academic testing conducted using appropriate adaptations for vision?
• Are the problems directly attributable to the student’s vision? For example:
  • Missing punctuation or difficulty differentiating math signs because of low acuity.
  • Slow reading rates because of the use of magnification devices, visual field loss, low visual acuity, etc.
  • Problems in maintaining place in reading passages because of nystagmus, visual field loss, etc.
• Has there been a recent change in the reading medium or a history of frequent changes to reading medium? Do educational records indicate consistent challenges in specific academic areas that do not appear to be related to changes in learning medium or significant changes in vision?

Reading

Research shows that blind braille readers activate the visual cortex despite the complete absence of vision, and there may be even stronger occipital lobe involvement in subjects who were blind early (Sadatao et al., 1996; Burton et al., 2002). Moreover, the core underlying aspects of reading are understood to be universal regardless of the format for input. Dyslexia is commonly understood as a problem with phonological processing, which is the same whether the input is tactile (braille) or visual (print). Phonological processing generally develops at the same rate and in the same order in sighted and visually impaired children (Veispak & Ghesquière, 2010), and braille readers who are struggling with phonological awareness or phonics lag behind in reading as well (Wall Emerson, Holbrook & D’Andrea, 2009).

However, visual impairments have the potential to impact many aspects of reading. Fluency (speed of reading) is one area known to be directly impacted by low vision – braille and large print readers read at a slower rate than fully sighted individuals (reviewed in Atkins, 2012). A careful evaluation will help disentangle, as much as possible, the impact of the visual impairment. Some examples of consideration are listed below.

Braille readers have specific challenges:

• Braille readers with early vision loss will have had much less early, incidental exposure to written language in their environment (e.g., seeing signs, lettering on toys, etc.). This early exposure to print (and thus the orthographic awareness) helps sighted students link the auditory/phonological with the written/orthographic.
• Tactile sensitivity, tactile perception, and tactile memory are essential skills for braille which are not needed for reading print. Early braille readers must be taught pre-reading skills which include tactile discrimination, scanning across a line of dots, and using both hands together.
• Braille involves reading letter by letter, as compared to reading print where a single visual fixation within the printed word can identify an entire word.
• When children are learning contracted braille, they must learn special rules for contractions. Also, contractions can span phonological boundaries, for example the word mONEy can use the ONE contraction. In addition, the same contraction can mean different things depending on the context.
• Reading braille is slower than reading print. Braille also takes up more physical space, so going back to review a passage can be challenging. This means information must be held in active memory for longer. In general, students who learn to read in braille are able to read faster than students who learn braille later. How much extra time is allowed for braille readers should be individualized to the student’s needs, and some recommend avoiding all timed tests (reviewed in Atkins, 2012).
• Overall, given all of the above, you can see that the general cognitive, phonological awareness, and memory load is higher in braille, especially for early learners.

Low vision students reading print also face challenges:

• Small font size can be challenging to read and reduced acuity can lead to misperception of letters (especially between visually similar letters such as O and Q). Reading font that is too small as well as reading enlarged font may take extra time. Scanning back in passages to find information can be challenging. Similar to braille readers, most students will need extra time or untimed tests for reading.
• The type of font may make a difference. In general, sans serif fonts are easier to read than serif fonts.
• Some students, such as students with CVI, may need extra spacing between letters (text kerning) to help reduce clutter and crowding difficulties.
• Learning to use an optical device or technology to access text.
• Readers with a reduced visual field may have a reduced “window” for viewing the word and may require longer and more frequent fixations and narrower saccades (impacting fluency).
• Reading can be a tiring process for partially sighted students.

Reading Connections: Strategies for Teaching Students with Visual Impairments is a great resource with strategies and guidance for reading instruction and assessment and includes the Kamei-Hannan and Ricci Reading Assessment, which is a comprehensive, informal assessment of basic reading skills at the preschool to eight grade level that is useful for low vision print and braille readers (Kamei-Hannan & Ricci, 2015).

Math

Math presents unique challenges to the blind or low vision student. It is difficult to separate the impact of vision from a primary math difficulty.

Care must be taken to appropriately introduce pre-math concepts in a meaningful way. A sighted student can instantaneously see an overview of a mathematical problem or formula, and quickly scan back and forth. A student reading math in braille will be more likely to have difficulty keeping track and must build an overview of the expression sequentially rather than seeing it holistically, placing a higher burden on working memory (van Leendert et al., 2019). In addition, students with strong verbal skills and auditory memory may be able to demonstrate procedural knowledge but still have challenges with conceptual understanding.

This article from the National Federation of the Blind talks about early math concepts and the Nemeth Code, a system for writing math concepts in braille. Pearson’s Accessibility Team for Assessments developed a freely accessible Nemeth Braille Code Curriculum for preschool to 2nd grade, Nemeth Braille Focused Lessons for grades 3 to 8, and Nemeth Symbol Library to support how to write symbols for kindergarten-level math to calculus.

Per Effective Methods for Delivering Mathematics Instruction to Students with Visual Impairments, “the most effective methods for delivering mathematics instruction to students with visual impairments, based on a summary of the literature…include using a combination of the abacus, braille codes, tactile materials, and concrete materials to teach mathematics skills to students with visual impairments (Brawand & Johnso, 2016). Please also see information from the Texas School for the Blind and Visually Impaired which discusses the use of the Abacus. Another tool is the Math Window, which allows students to manipulate magnetic tiles with Nemeth and large print to create and work on problems. Students also may use the braillewriter, large print or braille rulers, or talking calculators for solving math problems. With the use of specialized tools, evaluators need to be mindful of whether the student has proficiency with the tool. Consider whether the assessment activity is measuring the student’s mathematical knowledge or skill in the use of tools and adaptive materials, such as interpreting tactile graphics.

Writing

Writing is a complex activity that requires many underlying cognitive and motor skills. Blind and low vision students may write using paper and pen, standard keyboard, brailler, electronic braille device, or slate and stylus. Different fine motor coordination skills need to be developed for efficient use of these writing tools. Similar to fine motor considerations for manual handwriting and keyboarding evaluations, fine motor skills impact the use of mechanical braillewriters (e.g., finger strength, dexterity, and correct finger positioning), which impact the accuracy and efficiency of braillewriting.

There are a number of studies that suggest that students with visual impairments have similar writing abilities and challenges as sighted students. For example –

• On the WIAT-III Essay, low vision or blind students (excluding those with multiple disabilities) wrote essays not significantly different from the standardization sample of the WIAT (Savaiano & Hebert, 2019).
• In a large sample of braille writers, only 13% of errors were braille related (e.g., missing dots, horizontal/vertical transposition). The great majority of errors were phonetic (Erin & Wright, 2011).

How to help students struggling with academics

A TVI’s role is to integrate specialized compensatory instruction (including braille) with classroom-based literacy development as well as address areas of the Expanded Core Curriculum. TVIs collaborate with the classroom teacher. While TVI’s programs may address reading and math instruction, particularly in relation to compensatory instruction, they are not typically trained in standardized assessments or how to address learning disabilities. If a child is struggling, the student’s team may need to include a learning specialist, special education teacher, or resource specialist. Please see the webinar by the Texas School for the Blind on adapting the Wilson Reading System for blind and low vision students.

Blind students typically have age-appropriate phonological awareness skills. If phonological awareness skills are impaired in a student struggling to read braille, this could help support the diagnosis of Specific Learning Disorder in reading. Moreover, directly targeting phonological awareness may be an important area for remediation.

References

Atkins, S. (2012). Assessing the ability of blind and partially sighted people: are psychometric tests fair? Royal National Institute for Blind People Centre for Accessible Information, Birmingham. https://www.rnib.org.uk/documents/577/Psychometric_testing_report.docx

Burton, Snyder, A. Z., Conturo, T. E., Akbudak, E., Ollinger, J. M., & Raichle, M. E. (2002). Adaptive Changes in Early and Late Blind: A fMRI Study of Braille Reading. Journal of Neurophysiology, 87(1), 589–607. https://doi.org/10.1152/jn.00285.2001

Erin, J. N., & Wright, T. S. (2011). Learning to Write in Braille: An Analysis of Writing Samples from Participants in the Alphabetic Braille and Contracted (ABC) Braille Study. Journal of Visual Impairment & Blindness, 105(7), 389–401. https://doi.org/10.1177/0145482X1110500702.

Gillon, G. T., & Young, A. A. (2002). The Phonological-Awareness Skills of Children who are Blind. Journal of Visual Impairment & Blindness, 96(1), 38–49. https://doi.org/10.1177/0145482X0209600105.

Greaney, J., & Reason, R. (1999). Phonological processing in Braille. Dyslexia (Chichester, England), 5(4), 215–226. https://doi.org/10.1002/(SICI)1099-0909(199912).

Kamei-Hannan, Cheryl, and Leila Ansari Ricci. Reading Connections: Strategies for Teaching Students with Visual Impairments, American Foundation for the Blind Press, 2015. ProQuest Ebook Central, https://ebookcentral-proquest-com.proxy.lib.sfu.ca/lib/sfu-ebooks/detail.action?docID=4727804.

Layton, C. A., & Lock, R. H. (2001). Determining Learning Disabilities in Students with Low Vision. Journal of Visual Impairment & Blindness, 95(5), 288–299. https://doi.org/10.1177/0145482X0109500504

Sadato, Pascual-Leone, A., Grafmani, J., Ibañez, V., Deiber, M.-P., Dold, G., & Hallett, M. (1996). Activation of the primary visual cortex by Braille reading in blind subjects. Nature (London), 380(6574), 526–528. https://doi.org/10.1038/380526a0

Savaiano, M. E., & Hebert, M. (2019). A Cross-Sectional Examination of the Writing of Students with Visual Impairments. Journal of Visual Impairment & Blindness, 113(3), 260–273. https://doi.org/10.1177/0145482X19854921.

Tobin, M. J., & Hill, E. W. (2012). The development of reading skills in young partially sighted children. British Journal of Special Education, 39, 80–86.

van Leendert, A., Doorman, M., Drijvers, P., Pel, J., & van der Steen, J. (2019). An Exploratory Study of Reading Mathematical Expressions by Braille Readers. Journal of Visual Impairment & Blindness, 113(1), 68–80. https://doi.org/10.1177/0145482X18822024

Veispak, A., & Ghesquière, P. (2010). Could Specific Braille Reading Difficulties Result from Developmental Dyslexia? Journal of Visual Impairment & Blindness, 104(4), 228–238. https://doi.org/10.1177/0145482X1010400406.