Dr. Jeremy Sharp (01:18)
Hey folks, welcome back to the Testing Psychologist Podcast. I’ve got a clinical episode for you today, and I have a return guest for you today. I’m happy to welcome back Dr. Robin Peterson, who’s a board-certified pediatric neuropsychologist at Children’s Hospital, Colorado, and an associate professor of physical medicine and rehab at the University of Colorado School of Medicine. She has clinical and research interests in neurodevelopmental disorders and acquired brain injuries.
She’s authored over 40 peer-reviewed publications and is co-author of the books Diagnosing Learning Disorders from Science to Practice and Pediatric Neuropsychology, third edition, Research Theory and Practice from Guildford Press. Robin is active in teaching and training graduate students, interns, and postdoctoral fellows. Prior to becoming a neuropsychologist, she also taught kindergarten and first grade. So given all of that, Robin is the perfect person.
To be talking about learning disorders. So we’ve done quite a few episodes on learning disorders over the last few months because it continues to be a pretty fraught topic in our field in terms of how we’re defining them and how we diagnose them and and how we treat them. So we’re talking about lots of issues within this topic. We talk about why the field continues to struggle with defining and diagnosing learning disorders. Robin gives a
Pretty compelling pitch for why you know the word specific should not necessarily apply to learning disorders. We talk about comorbidity between dyslexia and ADHD and other clinical concerns. Certainly, you know, of course, we dive into the diagnostic part. So, how do we diagnose learning disorders? We go through the different models like discrepancy model, pattern of strengths and weaknesses, response to intervention, DSM, and evaluate all those frameworks from a critical lens.
What else? We talk about learning disorders in high IQ populations and clinical impairments, and we talk about writing disorders, which also continue to be, I think, poorly defined and measured. So there is a ton to take away from this conversation. Robin is super knowledgeable and presents these ideas in a way that I think are very easy to understand. So hope you enjoy this episode with Dr. Robin Peterson.
Dr. Jeremy Sharp (03:49)
Robin, hey, welcome back to the podcast.
Robin Peterson (03:52)
Hey, thanks so much for having me back. Excited to be here.
Dr. Jeremy Sharp (03:56)
good, good, good. Well, I’m excited to have you. Yes. like I said before we started to record, we’ve been I’ve had a number of episodes recently on learning disorders. So we have a little bit of a theme going on here over the last two or three months. And you’re a an important voice in that conversation. So I’m very grateful that you’re willing to be back.
Robin Peterson (04:16)
Great. Well yeah, as you know, it’s a topic that’s near and dear to my heart. And I think just because of how common they are, I would imagine would be very interesting to your listenership. So I’m glad to hear that’s been a focus of late.
Dr. Jeremy Sharp (04:28)
Yeah, yeah, definitely. Definitely. Well, that’s a good segue too. I mean, I always like to ask why this for my guests and especially for you. I mean, you’ve at this point made, I think, a bit of a career out of learning disorders and you know, multiple editions of your book and all kinds of things. So, I mean, what is it about this that feels important to you enough to to spend your time and energy on?
Robin Peterson (04:53)
Yeah, I mean I I do think I just have a very long history of interest in this topic. I, as you may know, I was a teacher before I was a psychologist. I always knew I wanted to work with kids in some capacity, but wasn’t sure how. and I was just really fascinated by child development. And so straight out of college I got a teaching certificate and was teaching kindergarten and first grade, so really
you know, those foundational years for kids learning to read. and I just found that I was especially kind of fascinated with and drawn to the kids that were having more trouble with learning than some of their classmates. And just to anticipate a little bit of what we’re going to talk about more today, you know, I think the kids that are the most striking to
teachers and parents and historically clinicians are kids who have these big kind of discrepancies or uneven things in their profile. So I still have a a picture that a little boy made for me when I was teaching first grade. And he was the kid that was like totally on the ball with math and the first one to raise his hand. And he was super curious and social and intellectually engaging and athletic, but he just was not learning to read the way that his
Dr. Jeremy Sharp (06:07)
Mm-hmm.
Robin Peterson (06:07)
peers were and it was like
a really marked struggle for him. And so that kind of kept me up at night. and I started learning a little bit more about specific learning disabilities and kind of consulted with some neuropsychologists when I was a teacher and realized like, that seems really cool and that’s what I want to do. And so that led me down the path. And then I applied to work in a lab with Bruce Pennington for my PhD that was focused on a lot of different things but kind of
one of the major projects at the time was related to relationships among speech language and reading disorders. And that’s really what I focused
Dr. Jeremy Sharp (06:40)
Mm.
Robin Peterson (06:41)
on throughout graduate school. and I think as I spent more time in this world, you know, those kids, like that little boy I mentioned, are of course super interesting. But the reality is there are lots of other kids who are also struggling in school who may not have such an uneven profile. And so I certainly saw those when I was a teacher, but you know, more.
Of my career, I think working with kids with medical complexity and lots of things that may cause brain development to proceed differently from early on, you know, may be at risk for kind of broader learning challenges too. And so just wanting to make sure that we understand those kids to the same degree and can provide them the best support possible so that they can thrive too has become a little bit of a passion of mine.
Dr. Jeremy Sharp (07:26)
Hm. Yeah. Yeah. Yeah. I t I feel like the teacher to psychologist pipeline is such a helpful one.
Robin Peterson (07:33)
Mm.
Dr. Jeremy Sharp (07:33)
and I know a few folks who’ve gone that route. And yeah, it gives you I don’t know, just having that additional perspective on kids is so valuable, I would imagine, and just informs your work even. Yeah.
Robin Peterson (07:43)
Absolutely. Absolutely. I
mean, I know people often said to me when I was transitioning, like, you understand how schools work. And that’s
Dr. Jeremy Sharp (07:50)
Mm-hmm.
Robin Peterson (07:50)
true to a degree, but I also think there are a lot of differences across different states and, you know, kinds
Dr. Jeremy Sharp (07:56)
Yeah.
Robin Peterson (07:57)
of school settings and stuff, and school practice changes. You know, I’ve been out of the schools for a long time now, but I think s something that has really stayed with me and continued to be powerful is just that I did have a long, solid
in kind of general typical child development
Dr. Jeremy Sharp (08:14)
Mm-hmm. Mm-hmm.
Robin Peterson (08:15)
that I think it’s harder to come up to speed on unless you’ve just interacted with lots and lots of kids before you become a child psychologist. So I’m really grateful for
Dr. Jeremy Sharp (08:23)
Yeah, yeah, that’s true.
Robin Peterson (08:25)
those experiences.
Dr. Jeremy Sharp (08:26)
Yeah, yeah, for sure. Well, so I wanna jump right into it and come out with a a per perhaps difficult question. but you
Robin Peterson (08:34)
Sure.
Dr. Jeremy Sharp (08:35)
know, having all these conversations around learning disorders over the last few months with different folks,
The the common theme is that we still are struggling to define and diagnose learning disorders. And I’m curious from your perspective, why are we still struggling to define and diagnose learning disorders at this point?
Robin Peterson (08:53)
Yeah, yeah,
this is a a provocative question and I think a good one. I think the first thing that I’ll say, and certainly I guess I should say I know it’s something that like the NIH has kind of pushed back on, like some of the big learning disability research center groups, like, okay, we’ve there’s been a lot of research on this all for a long time, like we we gotta kind of move on. and I do think there’s been a lot of progress.
And I think I’m not sure that we’re struggling more with learning disability kind of diagnosis or definition than we are other psychological or behaviorally defined disorders.
Dr. Jeremy Sharp (09:29)
Sure.
Robin Peterson (09:30)
yeah, I mean, I think if you look at what’s happened in sort of the broader field of mental health and how much dramatic change there’s been in what we call a disorder and how we define and diagnose and that.
Some of them are even more sort of shocking or or dramatic, right, than
Dr. Jeremy Sharp (09:49)
Mm-hmm.
Robin Peterson (09:51)
than the case of learning disorders. But you know, I think all of all of our psychological diagnoses really raise fundamental questions about kind of what is normal variability and what is a disorder. how do we impose something that’s by nature categorical?
Like a yes or no on something given, you know, as humans, we think categorically, but really essentially all categories are social constructions, and all of nature is really something that’s more distributed and continuous. and then I think the kind of other piece with learning disorders is that they do intersect with some more sort of culturally specific or defined.
Aspects of the human experience than some other mental disorders. So, you know, writing and reading are pretty recent cultural inventions of 5,000 years old or so. And so
Dr. Jeremy Sharp (10:43)
Uh-huh.
Robin Peterson (10:44)
certainly the cognitive and neuropsychological vulnerabilities for developing a learning disorder in those areas were likely present in the brains of people hundreds of thousands of years ago in our
Ancestors or you know, in cultures now that don’t have reading and writing, but it’s not clear that they will really have a functional impact, so wouldn’t be considered a disability in the same way. I think the situation with math is a little bit more complicated, in that you know, some version of basic numeracy was probably relevant going back further in our history, but certainly kind of higher level, more.
more complex math is also something that’s kind of more specific. And you know, the manifestations of those again, like the degree to which they’re problematic, can depend on the nature of a schooling system in a society, kind of the nature of work expectations, access to those things. So I think that just complicates the picture even more. Not something like,
Dr. Jeremy Sharp (11:42)
Yeah.
Robin Peterson (11:44)
you know,
Some emotional disturbance or behavioral problems, potentially. Potentially.
Dr. Jeremy Sharp (11:51)
Yeah, yeah. I mean,
Robin Peterson (11:52)
Yeah.
Dr. Jeremy Sharp (11:52)
you’re raising some questions that I think about I think about a lot. I mean, it comes up even in the context of I don’t know, ADHD or autism. It’s sort of like that tree if a tree falls in the forest question, you know? Like it’s kind
Robin Peterson (12:06)
Mm-hmm.
Dr. Jeremy Sharp (12:07)
of like if there was n if there were no expectations to be good at reading or math or socializing or executive functioning or whatever, would that even exist as a problem that we’re trying to digest?
You know what I mean? So
Robin Peterson (12:20)
Exactly,
exactly. And I think for some of the milder kind of presentations or you know, I think one thing that’s happened over time is that as there’s been less stigma with some of the mental health challenges, including neurodevelopmental differences, people are more willing to consider like getting a a diagnosis or a label and and seeking
Dr. Jeremy Sharp (12:40)
Mm-hmm.
Robin Peterson (12:41)
treatment and
I think arguably for some of those kind of milder presentations of, you know, ADHD or autism, like you really can see it as more of a a brainstyle,
Dr. Jeremy Sharp (12:54)
Mm.
Robin Peterson (12:55)
kind of just a way of being in the world. and the degree to which it is or isn’t impairing is very dependent on your environment, right?
Dr. Jeremy Sharp (13:04)
Absolutely.
Robin Peterson (13:06)
I don’t think that’s the case.
For every presentation, you know, I think we know like overall ADHD, for example, is associated with lots of long-term physical mental health risks, shorter lifespan, relationship problems, right? If you have a child with autism who has no functional communication and you know can’t let a parent know if they’re in pain or hungry. I mean, I think it’s hard to argue that that’s just kind of a style and not
causing real impairment for the child and family. But we’ve really broadened a lot of our diagnoses to capture that wide span.
Dr. Jeremy Sharp (13:44)
Right, right. Yes. So in an effort to maybe narrow this a little bit, I mean a lot of our conversation today I think is gonna revolve around this presentation that you did fairly recently. And so, you know, in there you talked about sort of two primary questions that a definition of learning disabilities should address. can you highlight those questions for us?
Robin Peterson (14:05)
Absolutely. Yeah. I mean, I think the simplest and in some ways most effective definition of a learning disability is just that it’s unexpected difficulty learning those fundamental academic skills of reading, writing, and math. and so the two questions that kind of immediately come up for any definition are how severe do those difficulties have to be?
Dr. Jeremy Sharp (14:26)
Yeah.
Robin Peterson (14:26)
so given that humans do almost everything, kind of their individual differences in almost everything.
You know, what’s the difference between, you know, being just maybe that just coming not quite as easily to you versus it being a disability? and then the other one is really how specific or how focused. You know, a lot of our diagnostic frameworks still use this terminology of specific. And as I mentioned at the beginning, I think kids who have a more isolated difficulty in one area tend to really be striking to parents and
Teachers and clinicians, and even, you know, historically going back, the very first published case example of dyslexia was based on a kid a lot like my little student who I told you about.
Dr. Jeremy Sharp (15:10)
Mm.
Robin Peterson (15:12)
but does that mean that somebody who has, you know, really broad difficulties impacting many aspects of thinking and learning doesn’t have a learning disability?
Dr. Jeremy Sharp (15:22)
Mm-hmm.
Mm-hmm.
Robin Peterson (15:24)
And you know, the field has kind of moved on that. We still require some specificity, but much less than we used to.
Dr. Jeremy Sharp (15:33)
Yeah, yeah. I want to dig into that a little bit more. I mean, the title of your presentation was How Specific Are Learning Disabilities? which was
Robin Peterson (15:39)
Yes.
Dr. Jeremy Sharp (15:39)
really interesting. That’s really compelling right from the get-go. I’ve never granted, you know, this is not my area of specialty necessarily, but you know, I’ve never really thought of it that way. And so could you just elaborate a little bit more on why you titled it that way and like what w why we’re like challenging this idea of specific learning disabilities?
Robin Peterson (15:57)
Yeah, absolutely. I mean, I think, you know, in the DSM and in idea, right? So the federal legal definition of learning disabilities, we have this nomenclature still of specific learning disabilities, specific
Dr. Jeremy Sharp (16:09)
Yeah.
Robin Peterson (16:09)
learning disorder. And I do think that really impacts how people think about these neurodevelopmental disabilities. And there’s an expectation that there be some real specificity or unevenness to the child’s profile. And
You know, I like to say that if you’ve ever like had a debate with a colleague or attended a case conference where people were disagreeing about whether a child had a learning disability, it’s pro most of the time it was probably about one of these two questions, right? Either they were kind of the severity, it wasn’t clear if it was really severe enough, or it was clear that they had, you know, for example, a reading problem, but the reading problem was not specific. And
Dr. Jeremy Sharp (16:51)
Isn’t it
Robin Peterson (16:52)
There’s a history for this in the field. We used to talk about specific language impairment, and the idea was that these were kids who had, you know, problems with language development, but were cognitively thought to be developing typically. and over time, you know, that it became clear that first of all, there’s a lot of kids who have language problems and would benefit from intervention who also had some challenges with kind of nonverbal cognitive
Processing. It also became clear that the developmental profile or the cognitive profile could change with development. So if you have an early language development, you’re at risk for kind of a a broadening gap with your peers in nonverbal problem solving, probably just because language is such an important way that we kind of learn about the world and learn to approach problems.
Dr. Jeremy Sharp (17:39)
Mm-hmm.
Robin Peterson (17:40)
so there’s been some precedent for moving away from that language. and I think that
The diagnostic criteria that really meant that we were diagnosing kids who did have those more specific profiles. So really that IQ discrepancy model that folks, many folks are still familiar with.
Good approaches to diagnosis. and we have lots of other evidence that I got into in that presentation, and one that we can review today if it would be helpful. that in terms of genetic causes, environmental causes to a degree, brain bases, and kind of even symptoms to a degree, the profiles of learning disabilities are really not very specific. And so
Dr. Jeremy Sharp (18:20)
Yeah.
Robin Peterson (18:21)
I think it’s time to revisit the nomenclature.
Dr. Jeremy Sharp (18:25)
Yeah, yeah, that’s fair. I mean, there are a couple situations that come up for me that I might throw out there for us to discuss. And I imagine a lot of us as clinicians have run into these situations. So the first one is either you know, you diagnose a learning disorder. Typically it’s a reading disorder. I feel like that’s, you know, just like statistically it’s more common or whatever. and you’re also diagnosing ADHD, you know, like there’s there’s
Robin Peterson (18:46)
Mm-hmm.
Dr. Jeremy Sharp (18:46)
a high comorbidity between learning issues and and ADHD. So that’s kind of situation number one.
Situation number two is and they’re not mutually exclusive, of course, but I’m gonna present them that way, is you know, you diagnose all three learning disorders. You know, it’s like reading, writing,
Robin Peterson (19:01)
Mm-hmm. Yep.
Dr. Jeremy Sharp (19:02)
and math. And it’s just it’s like broadly low in academic skills with a relatively, you know, intact IQ or cognitive ability. So
Robin Peterson (19:12)
Or at least not
at the level of intellectual disability, which is one of the main kind of ways that we require some specificity. still, yeah.
Dr. Jeremy Sharp (19:20)
Yes.
Yeah, yeah. So both of those situations, yeah, it makes me think like y about broadening this definition, I suppose, or even the terminology.
Robin Peterson (19:28)
Yeah. Those are yeah,
two really good examples. and they’re related, but I do think they raise somewhat different questions. So which one should we talk about first?
Dr. Jeremy Sharp (19:38)
Let’s do the ADHD one first, yeah. Kind of comorbidity with other neurodevelopmental.
Robin Peterson (19:40)
Yeah, okay. I mean, I think this is one
where we have really good data to speed to these questions. So as you indicated, there is a high comorbidity between dyslexia or reading disability and ADHD. It’s probably around twenty-five percent, but it’s gonna be higher when you see kids in clinical practice, just because we know kids with two problems are more likely to come to clinical attention than kids with one. So
Dr. Jeremy Sharp (20:06)
Yes, yes.
Robin Peterson (20:07)
and you know I think there was a lot of thinking for a long time that this wasn’t a true comorbidity or questions about that. So well, of course, if you have ADHD, you’re probably not gonna really pay very good attention to instruction, and so you might be
Dr. Jeremy Sharp (20:22)
Mm-hmm.
Robin Peterson (20:23)
behind in learning to read. Or if you have a true reading disability, you know, school’s gonna be unpleasant for you, and so you might just look sort of inattentive.
But there’s been a lot of research now really thoroughly investigating the relationship between these things. And we do know that there’s shared genetic risk factors, kind of shared neuropsychological vulnerabilities, and that it’s really what we call a a true comorbidity. So essentially that,
Dr. Jeremy Sharp (20:50)
Mm.
Robin Peterson (20:51)
you know, because there’s some shared underlying causes, if you have one, you are genuinely at higher risk for another.
Dr. Jeremy Sharp (20:59)
Yeah.
Robin Peterson (20:59)
and then we also know that the treatments are different. so the most effective treatment for reading problems is explicit, structured, direct, phonics-based, intensive, individualized reading instruction. and the best treatments for ADHD are often a combination of medication and kind of environmental modifications and behaviorally based therapies.
And there’s even been some, you know, I think intervention studies that took kids who had one or the other and tried both treatments, and it’s pretty clear the ADHD treatments don’t really transfer to big reading gains and the reading treatments don’t transfer to big ADHD gains. So I think
Dr. Jeremy Sharp (21:37)
Mm-hmm.
Robin Peterson (21:37)
essentially if both things are present, clinicians should feel very if symptoms are both are present, clinicians should feel very comfortable and confident diagnosing both and then recommending treatment plans geared towards.
Dr. Jeremy Sharp (21:50)
Yeah, yeah. That’s great. That’s great. Can you
Robin Peterson (21:53)
Yeah.
Dr. Jeremy Sharp (21:55)
this is a little bit of a detour, and we’ll
Robin Peterson (21:57)
Okay, yeah.
Dr. Jeremy Sharp (21:58)
see where this goes. Maybe it works, maybe it doesn’t. But, you know, people always like specifics, you know. So thinking about if we’re trying to differentiate ADHD from a from a reading disorder, you know, I these discussions do happen a lot. I guess like the diagnostic overshadowing, you know, where AD you know, you
Robin Peterson (22:14)
Yep, yep.
Dr. Jeremy Sharp (22:15)
say like you described with with the tension issues. what would
What are we looking for in the data to make sure that symptoms of both are present? Does that make sense?
Robin Peterson (22:26)
Yeah, I yeah. I mean, I guess what you would worry about is, you know, the kid who has a lot of classic symptoms of inattention, of being easily distracted and not persisting. but those are only happening during reading tasks in a kid who had a reading disability. that might feel
Dr. Jeremy Sharp (22:42)
Mm-hmm. Mm-hmm.
Robin Peterson (22:44)
less compelling.
Dr. Jeremy Sharp (22:46)
Mm-hmm.
Robin Peterson (22:47)
so I do think even though we know that learning to read is going to be especially effortful for a kid with
learning disability. And so it might not be surprising to hear that ADHD symptoms are more prominent in that setting.
Dr. Jeremy Sharp (23:00)
Mm-hmm.
Robin Peterson (23:02)
But you you certainly would expect to see them at least to a degree beyond that. Right. So I think exactly. So it could
Dr. Jeremy Sharp (23:09)
Right. Right. More consistently in other environments and yes.
Robin Peterson (23:13)
be a case of you know and this is something I I’ve gotten more and more comfortable with as time has gone on in my career. But
You know, not necessarily if that if say that were the presentation, if if one is if the dyslexia is crystal clear, there’s clearly some features of ADHD, but it’s, you know, primarily coming up during reading tasks and the child hasn’t had reading intervention yet, you know, kind of flagging it as something where it looks like there’s some risk for this and we want to monitor it, not saying no, there’s
Dr. Jeremy Sharp (23:41)
Mm-hmm.
Robin Peterson (23:41)
this is not ADHD because it’s due to dyslexia, but maybe not also making a firm diagnosis and kind of reevaluating that piece in a year or two.
And seeing how it goes as demands increase. I think the other piece that comes up is sometimes people will, clinicians will sort of label reading or spelling errors as inattentive. and they’ll sort of excuse they’ll say like, you know,
Dr. Jeremy Sharp (23:59)
Sure. Careless errors.
Robin Peterson (24:02)
they they made these problems, but it was clearly seemed inattentive. And, you know, I don’t think we have great data on what makes a reading or spelling error inattentive versus not.
Dr. Jeremy Sharp (24:13)
Mm.
Robin Peterson (24:14)
I
I think we know what dyslexic errors look like, right? And that includes things like whole word guesses, function word errors, so read you know, saying the instead of a or of kind of mixing up those little words. and those could look inattentive, but at least once kids get beyond, you know, that very early stage of of reading instruction,
Re-word recognition should be fairly automatic. And so even if they’re somewhat inattentive, we wouldn’t be expecting to see tons of those kinds of errors. So I’m not saying that you couldn’t, you know, here and there make an error just because you’re not paying the best attention, but if you’re seeing a kind of a consistent pattern of errors that feel similar to what a child with a learning disability would make, I would be hesitant to completely chalk it up to inattention.
Dr. Jeremy Sharp (25:03)
Certainly. Yeah. Thanks for taking that trip real quick. Yeah.
Robin Peterson (25:07)
Absolutely.
Dr. Jeremy Sharp (25:08)
Yeah. So listen let’s jump to that second scenario that I described
Robin Peterson (25:11)
Yeah.
Dr. Jeremy Sharp (25:12)
just a bit ago, like the the multiple learning disorder scenario.
Robin Peterson (25:16)
Absolutely. Yeah, this is one that I I think I’m particularly passionate about. So I think a really common situation that has come up is let’s say we have a child with a full-scale IQ summary reading score of 75, summary math
Dr. Jeremy Sharp (25:34)
Mm-hmm.
Robin Peterson (25:35)
score of 75, summary writing score of 75. nothing specific
Dr. Jeremy Sharp (25:38)
Mm-hmm.
Robin Peterson (25:39)
at all about their profile.
And the parents are saying they’re really struggling in school, they don’t want to go to school. the teachers are saying they’re, you know, far behind their classmates, their school testing is showing a big gap. They’ve been, you know, going to school regularly, they’ve been getting extra help and they’re not catching up. And so this is one that people like to fight about, whether this child has a learning disorder or not.
And you know, if you look at kind of the the DSM, if as long as you’ve ruled out the exclusionary criteria like lack of access to instruction in their preferred language and it’s not explained by visual or other sensory disturbance,
Dr. Jeremy Sharp (26:24)
Mm-hmm.
Robin Peterson (26:24)
you know, the child has a learning disorder and it’s impacting them in multiple areas.
And we really don’t have good evidence that that kind of profile needs a different type of intervention to learn to read or to learn to do math. And so I think one thing that happens is the insistence on having a specific profile potentially limits access to intervention for a child based on the fact that they have broader problems than.
the children who do qualify for services. And to me, that just seems illogical and potentially not ethical. so this is why, you know, of course, and this is also why I think the term specific learning disorder is so bad, because it’s obviously not a good description of what’s happening with that child. They seem to have
Dr. Jeremy Sharp (27:16)
Right.
Robin Peterson (27:18)
a pretty broad learning problem that impacts
school and academic learning and they need support for that.
Dr. Jeremy Sharp (27:26)
Right, right. Yeah. I mean I I’ve caught myself during these cases, you know, where you’re writing the report and it says specific learning disorder with impairment in reading, specific learning d disorder with impairment in math. You know, specific
Robin Peterson (27:35)
Mm-hmm. Mm-hmm.
Dr. Jeremy Sharp (27:37)
I’m like, this isn’t specific at all. Like this is a a a broad why am I writing this right now? But you know, that’s
Robin Peterson (27:40)
Right, right. Right. Right.
Dr. Jeremy Sharp (27:44)
the way that it’s set up in the D S of course. Yeah.
Robin Peterson (27:48)
Right, yeah. That’s not a U problem, that’s a that’s an us problem.
Dr. Jeremy Sharp (27:51)
So just to yeah, thank you. Thank you. So I mean just to put a fine point on it then, are you saying that we in those cases it is counterintuitive to even describe them as learning disorders? Or are you saying, yes, these are learning disorders? It’s just a broad learning disorder versus you know, specific learning disorders in each subject.
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Robin Peterson (30:36)
I think the I think it can be counterintuitive for people, but I think it’s the right thing to do to use that diagnostic label because I think that’s the most effective way to communicate with schools and other, you know, families and professionals about what kind of support the child needs.
Dr. Jeremy Sharp (30:53)
Mm, mm.
Robin Peterson (30:54)
I think depending on the situation,
going into some more detail about the fact that this is a broad profile and in that way it’s different from a child who has an isolated classic dyslexia kind of presentation.
Dr. Jeremy Sharp (31:06)
Mm-hmm. Mm-hmm.
Robin Peterson (31:10)
is can be appropriate. and we know that because I th I do think in the dyslexia community in particular, there can be a desire to really say no, dyslexia only impacts
kids who are cognitively, you know, doing really well in all other areas.
Dr. Jeremy Sharp (31:29)
Hmm. True.
Robin Peterson (31:30)
and, you know, I can understand where that comes from because there are many people with dyslexia who are also intellectually gifted, artistically gifted. it and that doesn’t describe every person with dyslexia, nor does having dyslexia necessarily mean you have those gifts. And
you know, I feel like there’s a little bit of a hidden kind of ableist message in that, like,
Dr. Jeremy Sharp (31:54)
Mm.
Robin Peterson (31:54)
it’s okay to have a learning disability as long as you’re excelling in these other ways. and the reality is
Dr. Jeremy Sharp (32:01)
Mm-hmm.
Robin Peterson (32:02)
like kids who have broader challenges, you know, have just as much kind of value in my mind as as, you know, human beings and in their community and and we know that explicit
systematic, phonics-based, individualized, intensive instruction is the best way to help those kids learn to read. And really the dyslexia community leads the way in providing that type of intervention. So I think it’s important not to make it harder for kids to access that based on their particular cognitive profile.
Dr. Jeremy Sharp (32:38)
Yeah, I appreciate you highlighting that. Yeah. And that just to emphasize too something you said a few minutes ago, which is that or rather I think I understood anyway, that we duh we don’t have evidence to suggest that that kind of intervention is any less helpful for kids with just sort of broad learning difficulties or lower cognitive ability. Is that right? Like that systematic instruction is gonna help kiddos.
Robin Peterson (33:04)
Yeah, I mean I think I think we have some evidence that your overall the child’s kind of overall level of language functioning predicts
Dr. Jeremy Sharp (33:12)
Mm-hmm.
Robin Peterson (33:13)
to some degree their ability to or their likelihood of responding well to reading intervention. So it’s not that that
Dr. Jeremy Sharp (33:21)
Mm-hmm.
Robin Peterson (33:22)
couldn’t be a factor, but the other, but what we also know is that there is not a different intervention that we would expect to be more so.
Based on the cognitive profile. So
Dr. Jeremy Sharp (33:32)
Okay, yeah. Okay. Thank you.
Robin Peterson (33:37)
and where there’s a lot, I think there’s a lot of variability in how kids respond to intervention that we just aren’t very good at predicting, like a lot of things. So it’s kind of like in my
Dr. Jeremy Sharp (33:45)
Yeah.
Robin Peterson (33:45)
mind, certainly everybody deserves a chance, right? At that. But even kids with intellectual disability, I think those are the approaches to learning to read that have the best support.
we probably still need more research on this, but
Dr. Jeremy Sharp (34:01)
Yes, yes.
Robin Peterson (34:03)
and usually what we know is if, you know, for mo a child and you know, of course if a child is cum, you know, completely nonverbal or something like that, that’s a different situation because reading and writing are a language-based skill and we generally teach kids to learn to read when they have around a five-year-old start to teach kids to learn to read when they have around a five-year-old level of language. So it
There could be some situations that are are different, or where working on literacy doesn’t make a ton of sense at that time. But
Dr. Jeremy Sharp (34:34)
Mm.
Robin Peterson (34:35)
usually for a child who’s got, you know, say at least a five-year-old kind of level of language, then that type of approach to literacy instruction and intervention makes the most sense. And then if they’re not responding, usually the next step is to increase the intensity of the intervention. So it could be more hours, more individualized.
it’s not like we need to abandon that and go to a completely different approach.
Dr. Jeremy Sharp (35:01)
Yes, yes. That’s helpful. I wanna go back to the clinical example, that second clinical example where we had the three, you know, kind of three learning disorders, so to speak, and you identified maybe this kid has a cognitive ability, you know, around seventy-five. You know, you we kinda like
Robin Peterson (35:16)
Mm-hmm.
Dr. Jeremy Sharp (35:18)
landed on this 75. So I’m getting in the diagnostic weeds here and splitting hairs
Robin Peterson (35:22)
Yeah.
Dr. Jeremy Sharp (35:22)
a little bit, but there are some folks I think who would maybe say, okay, this is a kid with borderline intellectual functioning. They would, you know,
Robin Peterson (35:30)
Mm-hmm.
Dr. Jeremy Sharp (35:30)
the that term. This is a kid with borderline intellectual functioning. These are not learning disorders per se. It’s just, you know, a a consequence of having low cognitive ability. How do you how would you respond to that?
Robin Peterson (35:44)
Yeah, so I mean, yes, you could describe it as borderline intellectual functioning. That seems fair. And you know, that as a diagnosis doesn’t carry the same kind of clinical impact or power that learning disorder diagnoses do. So it’s not an eligibility category under idea. it
Dr. Jeremy Sharp (36:03)
Mm-hmm.
Robin Peterson (36:04)
does not automatically buy you access to any type of
you know, services. So it’s not gonna open up disability benefits or you know, access to Colorado to case management agency, community centered board kind of thing. So
Dr. Jeremy Sharp (36:16)
Mm-hmm. Mm-hmm.
Robin Peterson (36:18)
it’s maybe helpful in terms of understanding the child’s profile. So you know you could use it for that purpose.
Dr. Jeremy Sharp (36:26)
Mm-hmm.
Robin Peterson (36:27)
but there’s no treatment for borderline that’s specifically for borderline intellectual functioning. There’s no
kind of resource that’s dependent on it. So
Dr. Jeremy Sharp (36:36)
Mm-hmm.
Robin Peterson (36:37)
and I think our, you know, our our current framework, the there is no exclusion that says the learning difficulties are not better explained by borderline intellectual functioning. So right? Yeah.
Dr. Jeremy Sharp (36:49)
That’s true. Yeah.
Robin Peterson (36:52)
so you could say both, and but in my mind the
The learning disorder diagnosis is probably the more important one in terms of helping that the child and family, which is ultimately what we’re trying to do most of the time now.
Dr. Jeremy Sharp (37:04)
Sure, sure. Yeah. I like the way that you frame that. So it seems like you are clearly coming from a place of advocacy, access, and as long as it’s, you know, within the rules, so to speak, of what the DSM is excluding or not excluding, you’re
Robin Peterson (37:17)
Mm-hmm.
Dr. Jeremy Sharp (37:18)
okay diagnosing those learning disorders if they, you know, meet the the threshold or are below the threshold, even in in light of relatively low cognitive ability. This is good to
Robin Peterson (37:30)
Absolutely.
Dr. Jeremy Sharp (37:31)
Yeah. I just want to highlight that. I mean, these are questions this is you know, this comes up a lot and there’s a lot of debate around this, right? So that’s why I’m spending so much
Robin Peterson (37:38)
Absolutely.
Dr. Jeremy Sharp (37:39)
time on it.
Robin Peterson (37:40)
You know, I appreciate it. And I know it’s one that depending on kind of where people trained and
Dr. Jeremy Sharp (37:46)
Mm-hmm.
Robin Peterson (37:47)
you know their own background, it can feel particularly uncomfortable for people. So I think it’s a really good one to spend some time talking through. One piece, another
Dr. Jeremy Sharp (37:53)
Yeah. Yeah, for sure. Well
Robin Peterson (37:57)
piece that can be helpful to know is that the you know the skills that an IQ test measures,
Is a pretty good list of the skills that predict most aspects of academic achievement. You know, we have, of course, we have phonological awareness, phoneme awareness that’s not, you know, on current IQ tests, and that does seem to have a special relationship to kind of early reading and spelling development. But, you know, other than that, across the board, overall language skills, working memory, processing speed.
fluid nonverbal reasoning, those things are all important for learning to do math and comprehension and and and learning to read too, learning to read and spell words, certainly verbal skills and work memory and processing speed, you know, play an important role in that. So, and that’s really why IQ tests were developed initially was to identify kids who might need extra help in school. And so this idea of saying like, you
You don’t score well on the things that predict school progress and you’re struggling in school, so therefore you don’t have a disability. Again, to me seems pretty illogical.
Dr. Jeremy Sharp (39:07)
Yeah, that’s a good way to put it. You’re right. You’re right. I think this is we can’t talk about this area of the discussion without dipping into the the way that we define learning disorder. So
Robin Peterson (39:20)
Yeah.
Dr. Jeremy Sharp (39:20)
sp and this example in particular kind of flies in the face of what we’ve historically, you know, the discrepancy model, where, you know, you define a learning disorder by a gap in achievement versus IQ. you said earlier
Robin Peterson (39:31)
Absolutely.
Dr. Jeremy Sharp (39:32)
that there’s not a lot of research to
support that that approach.
Robin Peterson (39:35)
Yeah, actually to the
contrary, I think we have a lot of research now showing us what’s wrong with that model. so one is
Dr. Jeremy Sharp (39:40)
Mm-hmm.
Robin Peterson (39:41)
part of it is what I just told you, right? Which is that IQ tests are pretty correlated with individual differences in IQ tests are pretty correlated with individual differences in academic achievement. we also know that kids who do and don’t meet those discrepancy criteria. So if you compare like average to above average cognitive ability and poor reading.
To kids with poor reading in the context of you know below average cognitive ability. they show similar difficulties with the more literacy-specific predictors, so similar difficulties with like phonological awareness, and they respond similarly to the same interventions. and there’s also some brain imaging data showing that kind of similar
patterns of atypical brain activation during reading and phonological awareness tasks. So there are differences, of course. The main differences are exactly what you would predict, which is that the kids with the lower cognitive abilities score lower on tasks of problem solving and you know more associated challenges with math and those kind of things.
Dr. Jeremy Sharp (40:43)
Mm-hmm.
Robin Peterson (40:44)
But from a pure kind of reading
lens, they’re not they’re not so different.
Dr. Jeremy Sharp (40:51)
Gotcha. Gotcha. Okay. So that’s what we that’s a discrepancy model. Let’s put that to the side. we’ve also there are
Robin Peterson (40:56)
Yeah, yeah.
Dr. Jeremy Sharp (40:58)
other many other ways that we’ve tried to define learning disabilities, right? So we’ve
Robin Peterson (41:02)
Yep.
Dr. Jeremy Sharp (41:02)
got like PSW pattern strengths and weaknesses. We’ve got RTI response to intervention. We’ve got the DSM
Robin Peterson (41:09)
Yep.
Dr. Jeremy Sharp (41:09)
also kind of floating over here.
Robin Peterson (41:12)
Yep.
Dr. Jeremy Sharp (41:12)
let’s walk through each of those and you
Robin Peterson (41:14)
Sure.
Dr. Jeremy Sharp (41:15)
know, give me your your take on, you know, the validity of each of these.
Robin Peterson (41:18)
Yeah,
yeah. So
Dr. Jeremy Sharp (41:19)
approaches.
Robin Peterson (41:20)
the other in addition to discrepancy, the other one that I think it’s time to retire is the PSW model. there’s not good evidence to support its use in practice. Jack Fletcher’s group really took the lead on this and I heard him once refer to that model as psychometric malfeasance, which I loved.
But essentially, you know, very small changes in the diagnostic criteria resulted in very large differences in who was actually identified. I think it is still rooted in this kind of incorrect assumption that people with learning disabilities must have kind of an uneven or specific profile. we also know that many people with clinically impairing
Academic learning problems do not meet PSW criteria. so I I don’t think and it’s just you know, it’s hard enough as we’ve talked about to agree on who has a learning disability when we are really looking at cut points on one kind of category, one to two categories of scores, right? Like, okay, we’re really looking at where your reading falls and
We have to rule out intellectual disability. So in to that extent, we’re looking at IQ as well. you know, with PSW, you could be trying to look at cut points across 10 different domains or something. It just kind of from a methodological statistical standpoint, it becomes a mass and I think not helpful clinically. RTI, I do think is a a a reasonable approach for diagnosing learning disorders or should be kind of
part of the approach, it is incorporated into the current DSM. the idea just being there that you know, we will need to make sure that kids are provided with high quality instruction and at least some initial intervention to know for sure that they really have a disability and not just kind of a an opportunity, lack of opportunity problem.
Dr. Jeremy Sharp (43:14)
Mm-hmm. Mm-hmm.
Mm-hmm.
Robin Peterson (43:17)
where I think I think there it can get tricky is if we have an older child who maybe didn’t have optimal early schooling, but at this point, you know, is very clearly struggling. And let’s say there’s, you know, a lot of compelling evidence. They have a strong family history, they’re making
you know, exactly the kind of errors we expect to see in learning disabilities. There’s a big functional impact. There’s an you know, I personally don’t feel like we always need to say, let’s do a year of intervention, additional intervention first before we make a diagnosis. So I think it’s a clinical judgment. and
Dr. Jeremy Sharp (43:53)
Mm-hmm. Mm-hmm.
Robin Peterson (43:54)
I think, you know, sometimes some good if if you do some real digging on the history, you might find out, there has been more intervention than we thought, you know, maybe they’ve been doing some
additional after school tutoring or something along those lines.
Dr. Jeremy Sharp (44:10)
Yeah. That’s a question that pops up for me in these in these cases is like how loosely do we define intervention? Right. So you get
Robin Peterson (44:18)
Mm-hmm. Mm-hmm.
Dr. Jeremy Sharp (44:19)
the kids, there’s a whole range of, you know, kids who’ve like done rigorous whatever, three times a week, you know, Orton Gillingham
Robin Peterson (44:26)
Sure, sure. Yep.
Dr. Jeremy Sharp (44:28)
for a year and they’re still struggling. That’s super easy and clear cut.
Robin Peterson (44:31)
Pretty clear
cut. Yep.
Dr. Jeremy Sharp (44:33)
But then you have the kids where it’s like, you know, they got pull out reading services for a couple months.
Robin Peterson (44:38)
Mm-hmm.
Dr. Jeremy Sharp (44:39)
We don’t know what curriculum. We don’t know for how long. Parents are just like, well, yeah, they got extra support. Then you have kids where like maybe the parents took them to Huntington for, you know, Yeah. Yeah.
Robin Peterson (44:48)
Yeah, yeah, or Kuman or yeah, what whatever it is. Yeah.
Dr. Jeremy Sharp (44:52)
So I’m curious, do you have any kind of rubric in your mind of, you know, what counts as intervention?
Robin Peterson (44:58)
Mm-hmm. that’s a good question. Probably I haven’t really made it explicit for myself. I you know, aga
Dr. Jeremy Sharp (45:04)
Right.
Robin Peterson (45:04)
again, it’s like if it’s a younger kid, I really have questions about whether they’ve gotten, you know, just good instruction yet. I always think we can say like, well, you know, we see features of this, but let’s kind of increase
the intervention and see what happens. And you know, we’re gonna look at it as more like you’re at risk for this diagnosis, but it’s not clear that you have it to the full extent and we want to, you know, re-evaluate. I think sometimes in my setting where you know I’m seeing kids who have underlying medical conditions that impact brain development. And so their evaluation is typically covered by medical insurance.
It’s a little bit easier for me to have families come back. And I I recognize
Dr. Jeremy Sharp (45:46)
yeah.
Robin Peterson (45:46)
in some private practice settings, if you know, families have to pay again out of pocket, that could be harder. so but per I do think there could be a model of like more of a follow-up consultation that’s not full testing, but you know, looking at educational records or having
Dr. Jeremy Sharp (46:00)
Mm-hmm. Mm-hmm.
Robin Peterson (46:01)
the kid come in for 10 minutes of testing on the test of word reading efficiency or something, right? That we know is pretty reliable about.
Dr. Jeremy Sharp (46:07)
Yeah.
Robin Peterson (46:08)
could be could be doable. So yeah, I don’t
Dr. Jeremy Sharp (46:11)
Sure, sure. Yeah.
Robin Peterson (46:12)
think I have an exact answer, but I try to take a nuanced approach and
and try to be comfortable with when it when it may be something that that can’t be fully resolved in one time point kind of revisiting. And I think that’s the nature of what the RTI model is is saying, right? Is that we’re really trying to look at this over time and what developmental trajectory the child is on and not just their scores at a single time.
Dr. Jeremy Sharp (46:40)
Right, right. So the other situation that comes up, fairly frequently, I think, are what I call life preserver kids, where they do respond quote unquote to the intervention and it will like nudge them up to let’s
Robin Peterson (46:53)
Mm-hmm.
Dr. Jeremy Sharp (46:54)
just call it like a standard score of eighty six, you know. and so
Robin Peterson (46:57)
Mm, mm.
Dr. Jeremy Sharp (46:58)
for the school districts, you know, it’s like above the threshold of
Robin Peterson (47:02)
Mm-hmm.
Dr. Jeremy Sharp (47:02)
a you know, identification of a learning disability. But then, you know.
If you take the intervention away, do they dip back down and it you know, is that response to intervention? Does that mean there’s no learning issue? But, you know, these are conversations that we have with the schools often.
Robin Peterson (47:18)
Right. This is about the house of your question, right? Think where it’s hard to ever get a satisfying answer for some kids. that’s I
Dr. Jeremy Sharp (47:24)
Mm.
Robin Peterson (47:24)
like that terminology, life preserver. And I’ve had more families talking about this as stealth dyslexia. Have you heard of this term? Yeah.
Dr. Jeremy Sharp (47:31)
Mm, yeah. Yeah.
Yeah. I feel like I hear yeah, people I hear I hear that term a lot and I’m never really sure what people mean, but yeah.
Robin Peterson (47:39)
Yeah,
I mean to me it’s just another way of talking about this fact that this really lies on a continuum.
Dr. Jeremy Sharp (47:46)
Mm-hmm.
Robin Peterson (47:47)
and so again, like there are going to be kids for whom neither answer is really satisfying because we are trying to make a categorical judgment on something that is not actually a category.
Dr. Jeremy Sharp (47:59)
Yes.
Robin Peterson (48:00)
and so really I think it comes down to
the clinical impact and how great is the impairment and you know what are the needs. And certainly there are cases like that where in a public school setting the child would not qualify for an IEP. but if I think that there is enough evidence of, you know, kind of a true vulnerability there and impairment, then I might make the diagnosis and advocate for a 504 plan.
That might provide some testing accommodations or you know, something along those lines that at least in the school setting, or access to assistive technology, you know, things that might be meaningfully helpful for that child.
Dr. Jeremy Sharp (48:37)
Mm-hmm. Mm-hmm.
Robin Peterson (48:39)
and then there might be cases where, you know, we know that like the comorbidity is on a continuum. The kind of genetic risk is on a continuum, right? So there are people that kind of it’s like, well, there are
first degree relative of someone with dyslexia. Their spelling’s not very good, maybe. but their, you know, reading is just fine. And so, you know, we many of us might have little features of this and that. And, you know, ultimately it’s a kind of a judgment call of if it’s over that line for a diagnosis.
Dr. Jeremy Sharp (49:11)
Yeah, yeah, yeah. I know I’m trying to pin you down on so many of these questions, you know, that are
Robin Peterson (49:16)
Yeah.
Dr. Jeremy Sharp (49:16)
that are truly judgment calls. And Matt, maybe that’s what emerges from this conversation is there we just have to make judgment calls sometimes. I’m okay with that.
Robin Peterson (49:24)
Yeah.
Dr. Jeremy Sharp (49:24)
I’m just working through a lot of these scenarios that that pop up and the questions that, you know, come up in these in these discussions. And I think the other one yeah, yeah. Go ahead.
Robin Peterson (49:32)
Absolutely. And I think too, just as
I go back to it might depend what the 86 what kind of test the 86 is on too. So,
Dr. Jeremy Sharp (49:40)
Mm.
Robin Peterson (49:40)
you know, we do know that like untimed real word reading is a lot less sensitive to learning disability than fluency or decoding. And so, you know, if you see a pattern of well, their phonemic decoding efficiency is sixty-five, but they’re
Untimed word reading is eighty six. That I might think about that differently. and so of course you have to assess those things to know, right? I think I think schools have gotten a lot better about this, but when I started training in gradu school, a lot of the testing that would be done through the schools was just kind of untimed, real word
Dr. Jeremy Sharp (50:17)
Mm-hmm, mm-hmm.
Robin Peterson (50:18)
reading. And so, you know, they might be saying, Well, there’s no evidence of learning disability and we would give different measures. You know, again, now I think schools have really
gotten good at assessing some of those things. So the some of those discrepancies are less.
Dr. Jeremy Sharp (50:32)
Yep, yep, that’s fair. So I’ll bring up one more scenario and then I promise I’ll stop you know, turning the screws on these clinical clinical questions.
Robin Peterson (50:39)
Mm-hmm.
Dr. Jeremy Sharp (50:40)
But so the other scenario that comes up, of course, and that people debate is you know, learning disorders in the context of really high IQ. So, you know, we
Robin Peterson (50:47)
Mm-hmm.
Dr. Jeremy Sharp (50:48)
have kids who are in the one whatever, one eighteen, one twenty three, one twenty nine, whatever. But then their
Robin Peterson (50:54)
Yeah.
Dr. Jeremy Sharp (50:54)
reading scores, math scores are ninety seven, one one.
Robin Peterson (50:59)
Yep.
Yep.
Dr. Jeremy Sharp (51:00)
You know,
how do you approach those cases and think about those?
Robin Peterson (51:03)
Yeah,
thank you for asking this question. I like this one a lot actually, because I think it’s one where we have pretty good scientific evidence, but it also just requires some clinical wisdom.
Dr. Jeremy Sharp (51:14)
Nice.
Robin Peterson (51:15)
so I I think you know we have all this research showing that the distinction between the IQ discrepancy model and the age discrepancy model of dyslexia,
It’s not a valid distinction, right? We know that kids who kind of meet both of those criteria benefit from the same kinds of intervention. The old the former DSM, the DSM 4, required both age and IQ discrepancy. And the DSM 5 improved on that by requiring only age discrepancy. But what you’re talking about is the kids who meet IQ discrepancy but not age discrepancy.
See, right.
Dr. Jeremy Sharp (51:58)
Right.
Robin Peterson (51:59)
and those kids we shouldn’t, I don’t think we should necessarily throw out the IQ discrepancy based on the fact that that distinction isn’t valid. instead, what comes up for me is is this one of those kind of like brain styles like we talked about, right? Where it’s like, well, this kid is a fantastic.
mathematician or you know has an architect type brain and just isn’t really a humanities person and that’s fine. or is it really impairing where this is a kid who you know wants to be taking all the AP and IB classes and you know is really passionate about the material and intellectually curious but like cannot keep up with the reading load because of the volume and speed.
That’s expected. And there is
Dr. Jeremy Sharp (52:50)
Yes.
Robin Peterson (52:50)
some brain imaging, a little bit of brain imaging research looking at these high IQ, poorer than expected, but still normal range readers, showing kind of that dyslexic type brain signature during reading tasks. So they probably have kind of some of the same underlying genetic and brain differences that you know cause a more severe reading problem.
And so really to me it comes down to this question of impairment. if there is clear evidence of impairment, I would offer a diagnosis in those cases. but I would be clear about what it means and doesn’t mean. It does not mean you qualify for an IEP. It does not
Dr. Jeremy Sharp (53:32)
Mm.
Robin Peterson (53:32)
mean that you qualify for accommodations through the College Board.
Dr. Jeremy Sharp (53:36)
Got him.
Robin Peterson (53:37)
I’m not saying that the families couldn’t try to pursue that, but that’s not what it means. It means this is a way of understanding your particular profile. And probably in most cases, you could argue for some accommodations through a 504 plan that might include things like like what we just talked about, extended time in some settings, you know, access to say audiobooks, audio textbooks or something along those lines.
So that’s where I personally land they that’s not exactly what the DSM says, but I think it’s more related to the current state of the science and you know fits better clinically. I think the the the one caveat or the one thing to be thoughtful about is like, well, who has the resources to be getting that diagnosis and getting access to those accommodations? And you know, we don’t want to set up a situation where
you know, families can kind of just pay for an evaluation and get something that they perceive as an advantage
Dr. Jeremy Sharp (54:33)
Mm.
Robin Peterson (54:33)
for their kid. But you know what, like as a society, that’s a big problem we have. And I I don’t think our evaluations are the leading edge of it. So
Dr. Jeremy Sharp (54:43)
Mm.
Robin Peterson (54:43)
you know, I mean there’s so many ways that resources are unfairly shared and advantages
Dr. Jeremy Sharp (54:47)
Right.
Robin Peterson (54:48)
to provide it to kids with financial resources. So yeah.
Dr. Jeremy Sharp (54:51)
Yeah, that’s another can of worms.
Yeah. Yeah. So how how would you define impairment in a case like that? What would you be looking for?
Robin Peterson (55:01)
Yeah, so I would be looking for kind of an emotional impact of the difficulties. So, you know, is the kid coming home every night and like, you know, melting down that they’re how stressed out they are about the homework and there’s
Dr. Jeremy Sharp (55:13)
Mm-hmm.
Robin Peterson (55:14)
not another good explanation for it.
Dr. Jeremy Sharp (55:17)
Mm-hmm.
Robin Peterson (55:17)
are they you know, not living up to their potential
Dr. Jeremy Sharp (55:21)
Mm.
Robin Peterson (55:22)
kind of according to multiple?
supporters, specifically in classes that have a very high reading or writing load and and
Dr. Jeremy Sharp (55:29)
Mm-hmm. Mm-hmm.
Robin Peterson (55:30)
are distressed about it. I think those to me would be some signs of impairment.
Dr. Jeremy Sharp (55:35)
Yeah, yeah. Well that that’s great. I mean that answered what was gonna be my next question, which is, you know, where do you land on the the like internal distress point of this discussion? You know, like where i
Robin Peterson (55:46)
Yeah.
Dr. Jeremy Sharp (55:47)
if there’s no like outward outward impairment in terms of poor grades or missing homework or, you know, things that people can see.
Are you okay with that sort of internal report of I’m so stressed, this is taking so much more effort than it should, that kind of thing? And it sounds like yes, like you would count that quote unquote as impairment.
Robin Peterson (56:06)
I would, yeah, I
know schools don’t from an again, back to our question about like what this means and doesn’t mean, right? Doesn’t mean you qualify for an IP. and and if the
Dr. Jeremy Sharp (56:15)
Mm-hmm.
Robin Peterson (56:15)
kid is still getting straight A’s, the school may say they don’t qualify for a 504 either. that could be a point of contention, but
Dr. Jeremy Sharp (56:21)
Mm-hmm. Mm-hmm.
Robin Peterson (56:24)
it it could be a discussion. but yes, to
Dr. Jeremy Sharp (56:26)
Yeah, yeah.
Robin Peterson (56:27)
me in terms of thinking about a clinical diagnosis, I think the internal distress is meaningful.
Dr. Jeremy Sharp (56:33)
Yeah, yeah, that’s fair. I agree. I just like to make sure that that’s clear. Yeah, yeah. So
Robin Peterson (56:38)
Yeah, yeah.
Dr. Jeremy Sharp (56:39)
I wanna I absolutely want to talk about writing. so
Robin Peterson (56:42)
good.
Dr. Jeremy Sharp (56:42)
yeah, yeah, yeah. I I feel like this is this dates all the way back to, you know, you and I both know Amy Connery, who’s down at children’s,
Robin Peterson (56:49)
So
Dr. Jeremy Sharp (56:50)
and you know, she was my like post grad supervisor, I suppose, or consultant when I was trying to get more in this neurosych realm. And
Robin Peterson (56:58)
Yeah.
Dr. Jeremy Sharp (56:58)
She was the first one to introduce this idea that we really have we don’t have a good idea of writing and we don’t have a good way to measure
Robin Peterson (57:05)
Aha, yeah.
Dr. Jeremy Sharp (57:06)
writing skills. so you talked about that a little bit too, and I wanna I wanna talk about that here in terms of yeah.
Robin Peterson (57:11)
Yeah, so let’s break writing down into a couple of different components.
well, really we could do this for all academic skills. So there’s more of the basic skills and then the more complex skills. So the basic skills are those things that we really emphasize and teach in early elementary school. they’re things that are, you know, very dependent on specific instruction. So that’s like reading words, spelling words, doing math calculation. And then as kids master those skills, then they’re ready.
To take on the more complex academic skills. So these are things like reading comprehension, written expression, math problem solving. They really require those basic skills. and then they kind of integrate those with more complex cognitive, you know, non-academic skills. And of course, those things are really ultimately the goal of education. And we continue working on those all the way through high school, college, and grad school for Zobaba.
so when we think about writing, we can distinguish basic writing, which is really spelling, arguably handwriting, punctuation and capitalization, and then higher level writing, which is like composition, writing stories or essays.
Dr. Jeremy Sharp (58:15)
Mm-hmm. Yes.
Robin Peterson (58:18)
so, in terms of basic writing, we can measure that very reliably. at least maybe not the handwriting as much. We don’t have as many measures of that, but certainly spelling, punctuation, and capitalization.
Writing conventions kind of things like it’s easy to measure, two different readers would agree on what makes it correct or incorrect. You can get a score. The scores tend to be pretty stable over time. Basic writing is extremely tied up with basic reading. So essentially
Dr. Jeremy Sharp (58:44)
Mm-hmm.
Robin Peterson (58:46)
there are two sides of the same coin. Kids learn them at the same time and in the same way. And the individual differences in them.
highly correlated. So if you are having trouble learning to read, you are also gonna have trouble learning to spell. and there is no evidence really for a separate specific learning disability in spelling or written conventions that is distinct from the specific learning disability in reading. So that is an yeah,
Dr. Jeremy Sharp (59:09)
Can I ask you a quick
Robin Peterson (59:10)
yeah, yeah.
Dr. Jeremy Sharp (59:11)
question on that, just like jumping in? can you help bridge the gap between reading concerns? Reading concerns and spelling, I totally get that. That makes intuitive sense. I got that. But the the bridge between reading concerns and writing convention, like capitalization and punctuation,
Robin Peterson (59:28)
yeah.
Dr. Jeremy Sharp (59:28)
how are those tied together exactly?
Robin Peterson (59:31)
Yeah, I think just because you know, they’re both and they’re probably not quite as strongly correlated, but they are quite correlated. I I think,
Dr. Jeremy Sharp (59:40)
Mm-hmm.
Robin Peterson (59:41)
you know, really the whole process of learning to read and write is about making these connections between oral language and written language. and in and some things that are, you know, essentially arbitrary. and a lot of and there’s a kind of a
a spiral, right? Where once you kind of get over that initial hump and have some basic ability to crack the code, a lot of it you learn just by i through experience. You get better you develop expertise and automaticity through experience. So if you can’t read very
Dr. Jeremy Sharp (1:00:11)
Mm-hmm.
Robin Peterson (1:00:11)
well, you’re not reading a whole lot. you know, you’re not gonna develop that fluency. There may also be something about kind of implicit
learning, kind of implicit statistical language learning for people with learning disabilities that would be relevant to learning the conventions as well. So I don’t know that I have that I or anybody has like a really full answer to that, but I think empirically we do see that they tend to track together.
Dr. Jeremy Sharp (1:00:38)
Yeah. Yeah. No, I appreciate you articulating that, man.
Robin Peterson (1:00:40)
so really like to me what what the way I think about dyslexia, because I think culturally that carries the most weight, and you know, that we have the International Dyslexia Association and most people have heard of it. And so I just describe that as a learning disability in basic literacy or basic reading and writing. So I would personally would not feel the need to like couch that as two different disabilities if we are seeing.
Dr. Jeremy Sharp (1:01:08)
Yes, yes.
Robin Peterson (1:01:10)
now it’s when we get to complex writing that the picture gets a lot murkier.
Dr. Jeremy Sharp (1:01:15)
Mm-hmm.
Robin Peterson (1:01:17)
so there’s a a long history, I think, of difficulties reliably measuring complex writing. and some folks might remember the SAT some years back tried to add a writing portion, and ultimately that attempted.
was abandoned because it just did not wasn’t reliable enough. So if you took the test
Dr. Jeremy Sharp (1:01:37)
Mm-hmm.
Robin Peterson (1:01:37)
once, you’d get one score, you took the test another time, you know, likely to have a pretty different score. and there’s some other examples of that in high stakes standardized testing. And so for kind of like performance based psychological tests, we have a few measures of writing available.
any one of them I don’t think meets the standards for reliability that we would expect to be able to make individual diagnosis. So it just depending on who kind of rates it, you would get bigger differences. We can also see like the nature of the type of tasks. So whether it’s a more like essay kind of fact-based approach or more.
A like narrative approach that’s gonna pull for different kids, like the their interest or background in the particular topic. Kids may perform differently on that. so there is some research showing that you can get to sort of like the expected level of reliability for individual diagnosis if you give, I think, four to six.
like essay type measures and have them scored by two raters, which in practice is not how anybody is doing this, right? I think some of the measures are like experimental measures that aren’t even available commercially.
Dr. Jeremy Sharp (1:02:51)
Okay. That sounds easy. Yeah, that sounds super easy to do. Yeah. Yep. Yep.
Robin Peterson (1:03:00)
So that’s where I think it gets tricky to think about like a specific learning disability in written composition. I don’t know that we’re there yet as a field to really be.
Diagnosing that regularly.
Dr. Jeremy Sharp (1:03:14)
Right, right. Yeah. Yeah. And I mean I’ve heard a lot of discussion too, just around, you know, the executive functioning load in
Robin Peterson (1:03:25)
Mm-hmm.
Dr. Jeremy Sharp (1:03:26)
written composition and how yeah, is that separate is that a separate skill set specific to writing
Robin Peterson (1:03:30)
Yeah. A hundred percent.
Dr. Jeremy Sharp (1:03:33)
independent of just executive functioning, like organization.
Robin Peterson (1:03:36)
Right.
I mean, I think of we know there’s really meaningful individual differences in these skills. We also know probably, you know, some of them can be taught. I think the reality is that like most kids who really significantly struggle with reading with writing composition, you know, they may have dyslexia.
They may have ADHD or kind of subclinical ADHD and executive functioning challenges. They may have a language problem. Like there may be a kind of an existing neurodevelopmental disorder diagnosis that’s a little better kind of validated that could be used and might help if what you’re trying to do is buy access to kind of services or supports, you might be able to use that.
Dr. Jeremy Sharp (1:04:23)
Yeah. Yeah.
Robin Peterson (1:04:24)
I do think if
you know you have a practice where you have a lot of people coming to you specifically with writing concerns and then giving at least giving multiple measures of writing would be important at the very least.
Dr. Jeremy Sharp (1:04:38)
Yeah, yeah. Can I put
you on the spot and ask if you have any favorites?
Robin Peterson (1:04:42)
No, I don’t like any of them.
Dr. Jeremy Sharp (1:04:43)
Great. Great. That’s
Robin Peterson (1:04:45)
Sorry.
Dr. Jeremy Sharp (1:04:46)
the that’s the honesty I’m looking for here, Robin. Yeah. Yeah. It is tough.
Robin Peterson (1:04:50)
Yeah, I don’t think there’s
a ton of options out there. So it’s kind of like if you’re trying to give multiple measures, you’re probably giving the ones that are available.
Dr. Jeremy Sharp (1:04:58)
Yeah, there’s not yeah, not that many. Okay. Well maybe maybe we start to close where we started, which is, you know, going forward, thinking about the possibility of a shift, almost a shift in terminology, you know, like you maybe advocate something like a like developmental learning disability versus specific learning disability. Yeah. Talk talk me through your thinking on that.
Robin Peterson (1:05:19)
Yeah. Yeah. Yeah. Yeah. I mean, that
is very much what happened in the specific language impairment example that we talked about. So really the kind of expert consensus around that diagnosis now is that developmental language disorder is better. I think it captures the fact that this is something that unfolds over time and is rooted in early brain development.
The ICD actually uses the terminology of developmental learning disorder. Ironically,
Dr. Jeremy Sharp (1:05:50)
Mm.
Robin Peterson (1:05:51)
they still require IQ discrepancy. So they haven’t gotten the full message, but there is some precedent now for at least using that terminology. And I do think it would avoid some of the discomfort and confusion that a lot
Dr. Jeremy Sharp (1:06:04)
Mm-hmm.
Robin Peterson (1:06:04)
of times we face when we are seeing kids with clear learning problems.
who don’t have a very specific profile.
Dr. Jeremy Sharp (1:06:13)
Sure. Sure. Okay. Yeah, I can get on board with that. I can get on board with that. And I know there’s a lot that we could
Robin Peterson (1:06:18)
Awesome.
Dr. Jeremy Sharp (1:06:19)
talk about in terms of brain stuff, genetic stuff, you know, that might support something like that,
Robin Peterson (1:06:23)
Yeah, absolutely.
Dr. Jeremy Sharp (1:06:26)
Where else? I mean, maybe this is a a good sort of last question, but where do you see us headed with all of this over the next, I don’t know, three, five, ten years? research wise, defining learning issues. What are you seeing?
Robin Peterson (1:06:40)
Yeah, yeah.
that’s a good question. I mean, I think I am not really an intervention person, but I do think you know, dyslexia has been kind of the leading edge of learning disability science in so many ways, and definitely
Dr. Jeremy Sharp (1:06:55)
Mm-hmm.
Robin Peterson (1:06:56)
that includes on the intervention side. so I think we know some about like math intervention and
what the you know, the writing intervention can be part of dyslexia. But I think that’s often one that I struggle with clinically is like, you know, what how exactly concretely, you know, should I be directing the school or it, you know, if it’s a family that wants outside resources, like where do I send them to get really top notch math support? So that seems like a big important next step.
I think continuing to really understand the relationships among you know different manifestations of learning disorders as well as their relationships to other kind of neurodevelopmental presentations. I think we’ve made a lot of progress on that, but really that’s been kind of a increasing focus just in the past few decades. So I think there’s a lot of work
Dr. Jeremy Sharp (1:07:50)
Mm-hmm.
Robin Peterson (1:07:51)
still to be done there.
and ultimately I think that will lead to some restructuring of our diagnostic systems and categories and you know, there’ll probably be some some lumping and some splitting. I mean, as much as we understand about learning disabilities and ADHD and how and why they’re connected, I think it it is still there is kind of a puzzle there. just
Dr. Jeremy Sharp (1:08:12)
Mm-hmm.
Robin Peterson (1:08:12)
in that they’re pretty different on the surface. And yet they’re, you know, very common and
very connected. so there’s probably a lot of other directions to go too, but those are a certainly a few that come to mind for me.
Dr. Jeremy Sharp (1:08:28)
Great, great. I appreciate you sharing all this with us. You know, I have really enjoyed our conversations and especially this one. I mean, you always bring this like research informed approach with coupled with real life experience, both as a teacher and a neuropsychologist. It’s yeah, I I just appreciate the kind of depth that we can go to in these conversations. So thanks for being here again.
Robin Peterson (1:08:51)
Well, I appreciate that
and I enjoy talking with you and also am really grateful for what you’re doing for our local community as well as the broader field in terms of this podcast. So keep I hope you keep doing it.
Dr. Jeremy Sharp (1:09:02)
Hmm. I appreciate
that. Well, thank you. Thank you. If people do want to learn more about you or check out your stuff, you got some books, what’s the where’s the best place to find find you, find your writings and research and so forth.
Robin Peterson (1:09:16)
yeah, yeah. I
try to keep a relatively low profile online. But yes, I do
Dr. Jeremy Sharp (1:09:21)
Mm-hmm.
Robin Peterson (1:09:22)
I co-wrote a book and co ed on on diagnosing learning disorders and co edited the most recent edition of the pediatric neuropsychology text. Both of those are published by Guilford Press. and have a web page of some sort through University of Colorado, where I’m on the faculty.
I folks are always welcome to just reach out to me directly as well. My email. I I work at Children’s Hospital, Colorado. And so my email is just my first name dot last name at children’s Colorado dot or G.
Dr. Jeremy Sharp (1:09:53)
Great. Great. Yeah, we’ll put all that in the show notes. and I’ll just personal endorsement for your learning disorders book. You know, that’s been on my shelf for years and have gone back to it many times, give it to our interns
Robin Peterson (1:10:04)
I love to hear that.
Dr. Jeremy Sharp (1:10:06)
and postdocs. Yeah, it’s fantastic. So yeah, thanks again for everything
Robin Peterson (1:10:09)
Super.
Dr. Jeremy Sharp (1:10:10)
you’re doing and for being here.
Robin Peterson (1:10:11)
All right, take care.
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