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Cheryl Weinstein, Ph.D.

Cheryl Weinstein, Ph.D. , is board-certified in clinical neuropsychology and is in private practice in the Boston-Chestnut Hill, Massachusetts, area. Her primary focus is on the development of treatment-oriented neuropsychological evaluations for learning-disabled sixteen-year-olds to middle-aged adults. She looks at the influence of medical disorders (e.g., diabetes, cardiovascular disease, lupus, multiple sclerosis) on young adults through to the geriatric population, with a focus placed on "good cerebral hygiene" as part of the treatment plan. In addition, Dr. Weinstein has served as past president of the Massachusetts Neuropsychological Society, is involved in the training of neuropsychology fellows in a major Harvard teaching hospital program, and is an Assistant Professor of Psychology at Harvard Medical School. She spoke with us in June, 2003.

• What is a learning disability? What are the different types of learning disabilities?
• What causes learning disabilities?
• What, if any, connections exist between learning disabilities? Do they have anything in common?
• Don't all people have some form of learning difficulty? Aren't learning disabilities simply a matter of degree?
• Are there early signs of learning disabilities?
• How can a parent determine if a child has a learning disability?
• What can parents do once their child is diagnosed? Where can they go for help?
• What kinds of medical, behavioral, and holistic treatments are available? What are the pros and cons of each type?
• What if parents live far away from the care their child needs? What can they do?
• What can parents do when they believe their child is struggling in school but have been told the child does not qualify for special education?
• What should parents keep in mind when talking with a child about his or her learning disability?
• How might a parent's own learning disability impact how he or she responds to their child?
• What are researchers learning about the nature and treatment of learning disabilities? What research looks most promising?

What is a learning disability? What are the different types of learning disabilities?

Cheryl Weinstein, Ph.D.: A learning disability, according to the Individuals with Disabilities Act (IDEA), is a disorder in one or more of the basic cognitive abilities involved in understanding or using spoken or written language. This may lead to an imperfect ability to listen, think, speak, read, write, spell, or do mathematical calculations. The term includes such conditions as perceptual handicaps, brain injury, minimal brain dysfunction, dyslexia, and developmental aphasia. The term does not include children who have learning problems that are primarily the result of visual, hearing, or motor handicaps; mental retardation; emotional disturbance; or environmental, cultural, or economic disadvantage.

Some experts have questioned whether this definition of learning disability is appropriate for learning-disabled adults. Dr. Robert Mapou, Vice President of the American Academy of Clinical Neuropsychology, suggests that a different definition is needed and describes an adult learning disability as being present from birth and influencing a specific area of cognitive functioning as well as the entire course of personality development. Difficulties can occur and co-exist with good intelligence and many other good abilities (e.g., excellent silent reading abilities but poor oral reading, spelling and writing). The specific weaknesses in cognition occur in a way that makes sense based on what we know about the brain, and these weaknesses can affect spoken language, written language, mathematics, visual abilities, executive functions and problem-solving abilities, attention, or learning and memory. A learning disability may also limit one or more aspects of a person's life (e.g., school, work, home and social life). In addition, the learning problems are not better explained by an acquired neurological disorder either in childhood or later in life, mental retardation, and cultural factors such as not speaking English as a first language, economic circumstances, psychiatric disorders, or lack of education.

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What causes learning disabilities?

Cheryl Weinstein, Ph.D.: The most is known about the learning disability known as dyslexia. Individuals with dyslexia do not have the typical pattern of left hemisphere brain organization for reading. Dr. Sally Shaywitz at Yale University (2003) has done remarkable research with functional magnetic resonance imagings (MRIs) showing that dyslexic adults have under-activation of the reading area of the brain and over-activation of brain regions responsible for attention and recognition of sounds. It is no wonder that the adult with a reading disorder is more fatigued after work. Their brain is literally working harder.

More generally, there are multiple factors that cause learning disabilities, including atypical brain organization. Specifically, there may be differences in cells or in the basic "hard-wiring" of the brain. One patient explained that his brain "was wired by a non-union electrician." There also may be differences in brain development due to metabolic disorders such as maternal diabetes or thyroid disease. Parental alcohol abuse and maternal smoking are well-known agents contributing to childhood learning problems. In addition, there may be stress to the baby during birth when there is sudden lack of oxygen to the baby's brain (anoxic events).

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What, if any, connections exist between learning disabilities? Do they have anything in common?

Cheryl Weinstein, Ph.D.: This is a very interesting question. The first thought that comes to mind is that a learning disability is commonly misattributed to poor motivation, laziness, or other psychological phenomena. This can lead to a negative effect on the child's sense of self. Dr. Mel Levine writes that cognitive functions and dysfunction play into overall life and happiness for every adult and child. It is tragic when the individual struggles and does not know what the struggle is about. The goal is to help individuals with learning disabilities to know and appreciate their strengths and develop good compensatory strategies. Levine sees the brains of learning-disabled individuals as "highly specialized brains that were not designed to be well-rounded." If the parent, child, and educational system appreciate this fact, the prognosis for the individual with a learning disability improves markedly.

In my practice, I am more prone to see individuals in whom the learning problems are "silent." These individuals struggle with learning but attribute problems to "math anxiety," "shyness," or wanting to "keep up with her brothers!" It is only when the learning load is too great that the cognitive difficulties become more apparent. For example, a young woman I know has struggled since the fourth grade, but the struggle was attributed to her worry about her parent's serious illness. When her anxiety became overwhelming during college, a neuropsychological evaluation indicated that anxiety and low self-esteem were present and that reading and writing fluency were seriously slowed relative to her excellent intellect. Thus, misattributing learning problems to psychological phenomena may significantly influence personality development.

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Don't all people have some form of learning difficulty? Aren't learning disabilities simply a matter of degree?

Cheryl Weinstein, Ph.D.: There is normal variation in all performances. We don't generally expect an individual to be equally strong in all areas. One can also move from an area of competence to an area of weakness, but we hope that individuals elect to work in their areas of strength. For example, I hope I am performing successfully as a neuropsychologist using my verbal strengths. If I made the poor choice of working as an engineer on Boston's Big Dig, my problems in that work environment would not represent a learning disability. Instead, I would have made a very bad decision, since mathematics and dealing with spatial relationships are not my areas of strength.

A learning disability is not the result of a poor choice made by someone. It is the result of specific learning problems in an individual with good intellect. The learning performances for these individuals are at least 1.5 to 2 standard deviations below their intellect. For example, if an individual has an overall intellect at the 50th percentile rank and their reading skills are at the 2nd percentile rank, the diagnosis of a reading disability would be in order.

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Are there early signs of learning disabilities?

Cheryl Weinstein, Ph.D.: First, one should ask if the child has risk factors for learning disabilities such as premature or difficult birth, serious illnesses or injuries in childhood, frequent ear infections and drainage tube placement or sleep disorders. Second, looking at school performance may shed light on a child's learning abilities. Does a child experience difficulties at the start of kindergarten or first grade? Is it harder for a child to separate? Does he or she experience increased anxiety? Third, it is helpful to observe how a child progresses through school. Does he have trouble learning to read, write, spell or do math? Is there a change in performance at a time when increased responsibility is needed, such as in the fourth grade or junior high school? Does performance begin to drop as the reading and writing load becomes greater? We find that some very intelligent learning-disabled students begin to experience difficulties at the college level. There is no parent to organize them, cook them meals, or get them to sleep on time. With sleep deprivation and increased work load, reading or writing problems become more apparent. I might point out to some college students that they now have a real problem because "their executive secretary didn't come to school with them!"

Problems with socialization are often overlooked. Does the child have trouble making friends? Does the child appear excessively shy and prefer to watch other children? Does the child speak like a little professor and talk on and on about a very specific topic that is uninteresting to other children? Does the child get into trouble acting like the "class clown or have trouble sitting still?" In general, problems with social perception in a child due to visual integration deficits are more likely to be missed, whereas a child with language-based problems is more readily identified. For example, teachers are more likely to focus on a reading problem than a child's difficulties understanding facial expressions, which is a highly complex visual activity.

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How can a parent determine if a child has a learning disability?

Cheryl Weinstein, Ph.D.: The parent may want to first discuss their child's learning with the classroom teacher or an objective professional. If there is concern about the child's academic or emotional performance, then a comprehensive assessment should be considered. Shorter evaluations that only assess intellectual abilities and academic skills may fall short because speed of processing information may be missed. In a more intensive neuropsychological evaluation, we can understand how a child's learning is influenced by the "executive functions": planning, prioritizing, organizing, integrating, memorizing, and manipulating information. For example, if the child cannot hold on to new information or retrieve material when needed, there is a breakdown in the learning process. Assessment of language skills is also important because problems processing, "taking in," and generating language influence educational and social progress. Finally, psychological development must be clarified. Specifically, are behavioral problems (depression, anxiety, obsessive behaviors) contributing to reduced learning? As noted above, learning problems can influence the entire course of personality development and, if there is a mismatch between the child's temperament and the expectations of parents and teachers, unfortunate problems may arise.

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What can parents do once their child is diagnosed? Where can they go for help?

Cheryl Weinstein, Ph.D.: A good comprehensive neuropsychological evaluation should provide extensive guidance about treatment options. Anyone can point out deficits, but the goal of a comprehensive evaluation is to clarify where there is breakdown in performance, when there is a breakdown in performance, and the conditions under which a child can recoup. Therefore, before beginning the evaluation process, it is important to negotiate with the neuropsychologist/educational specialist to make certain that there is an individualized evaluation. This means that the assessment process leads to treatment recommendations that are geared to the child's strengths and weaknesses. Hopefully, the assessment process will be a positive experience so that child and parents understand the results. So often, college students present for reevaluation having never seen their previous evaluations. This is unfortunate because they remain uninformed about who they are and therefore never have the opportunity to "own" their learning abilities.

Jane Holmes Bernstein, Director of Neuropsychology at Children's Hospital in Boston, also recommends that the neuropsychological evaluation indicate future risks for the child. If parents are aware that their child may have more problems with transitions or may have difficulty learning a foreign language, then plans can be put in place to access help at critical points. In summary, the best thing parents can do once their child is diagnosed is to make sure that a competent and qualified neuropsychologist/educational psychologist completes an individualized evaluation of all relevant biological, psychological, and social factors. The report must contain recommendations for implementing strategies to help the emotional and academic growth of the child, the family, and teachers. Computerized reports will not do, and a report filled with neuropsychological babble is unacceptable!

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What kinds of medical, behavioral, and holistic treatments are available? What are the pros and cons of each type?

Cheryl Weinstein, Ph.D.: Multiple interventions that look at all relevant biological, psychological, and social factors are essential and comprise a general principle of treatment. We all want that magic bullet to take care of learning problems. Unfortunately, the belief that medication alone will work is too readily embraced. Likewise, the belief that behavioral strategies alone are enough contains both risks and benefits. When family members say "Oh… no meds… no meds," I might say, "If your child had diabetes, you would run to Joslin Diabetes Center for insulin treatments" or "If your child had heart disease, you would be at Children's Hospital immediately to get medications." When parents agree with my statements, I then ask, "Can you explain why the pancreas and the heart require medication and the brain does not?" This is a crucial issue because there is an unfortunate assumption that brain-based functions are controlled by "will and motivation" rather that brain structure, brain interactions, and neurotransmitters, etc.

The most important treatment, however, may simply be someone helping the child/adolescent/young adult accept who they are and determine the best ways to move on. I recently evaluated a young man who recalled that his teacher had told him that his "brain didn't work quite right with all of his internal supports, but, when he used external supports, he moved at a high level and all his great ideas came together." He spent the rest of his education developing those external supports, and what he has achieved is admirable. He held on to the thoughts expressed by his teacher because she believed in him and gave him hope for the future.

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What if parents live far away from the care their child needs? What can they do?

Cheryl Weinstein, Ph.D.: The first order of business is obtaining an accurate diagnosis by a qualified neuropsychologist/educational specialist. Parents can contact the American Psychological Association in Washington, D.C., or the American Board of Professional Psychology for referrals to qualified neuropsychologists or educational psychologists.

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What can parents do when they believe their child is struggling in school but have been told the child does not qualify for special education?

Cheryl Weinstein, Ph.D.: A parent should first call their state's Neuropsychological Association for the names of child neuropsychologists who specialize in educational assessments and understand the public school system. Any assessment, however, must focus on current strengths, weakness and risks at crucial transition points in the educational process. Thus, though the child may not need special education services in elementary school, the demands of high school may overwhelm him or her. When dealing with the school system, it is always important to understand that the education of your child is a collaborative process. After all, the school wants to help your child succeed too. When I see high school and college students in my practice, I often read reports from their kindergarten teachers in which potential problems were first identified. However, when their parents agreed only to "watch" them, those problems were left unaddressed. Or, the school may have identified a problem, but the high school student absolutely wouldn't go to a learning center!

We all hear about school budget cuts and schools being overwhelmed with legitimate learning-disabled students. Clearly, there are unfortunate instances when a child needs special services but his or her learning disability goes unnoticed. At the same time, a collaborative process with the school system does work, and it has been my experience that, given dependable documentation of significant cognitive difficulties in a child, a school system will respond.

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What should parents keep in mind when talking with a child about his or her learning disability?

Cheryl Weinstein, Ph.D.: Parents should try to protect a child from humiliation, but this does not mean hiding the fact that the child has a learning disability. Instead, practicing resiliency, identification, and appreciation of special strengths and ways to compensate are essential. Dr. Sam Goldstein of the University of Utah's Department of Psychiatry believes that parents must help their child deal with worry and anxiety and that this is just as important as learning reading and math! Furthermore, protecting children from the burden of their parent's worries is essential. Turning to support groups for help and advice may make this process less difficult. I have spent my entire adult career understanding neuropsychological and psychological principles. As I begin to teach parents about their children's learning difficulties, it is important for me to let them know that I understand that neuropsychology is not something they elected to learn. But, though it may be painful for them, ongoing education and therapy can be remarkably helpful. Booster classes are always needed, and professionals cannot expect parents to "get it" just because it is written in a report.

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How might a parent's own learning disability impact how he or she responds to their child?

Cheryl Weinstein, Ph.D.: There are several important issues that come to mind. First, because a parent's own learning disability may give them a better understanding of learning problems, it influences how they react to their child. So often, after an evaluation is completed, a parent will say, "That's me." Problems, however, may arise. It is often painful to watch one's own child relive difficulties that one has experienced in childhood.

It is also odd that we expect parents with learning disabilities to teach their children skills that they themselves might not have. We do not expect parents with Parkinson's disease to teach their children to run fast, nor do we expect someone with diabetes to teach their child to make sugar cookies. Yet we continually expect parents with ADHD or social learning difficulties to vigilantly help their children develop organizational and socialization skills.

At the other end of the spectrum are parents with learning problems who naively think that, with extra hard work, they can make their children's learning problems go away. Understanding that one cannot "outgrow" a learning disability will allow us to develop more realistic ways to help parents and grandparents. An excellent resource for parents of children with learning disabilities is "How Do Good Learning Disabled Minds Develop?" by Dr. Mel Levine. Children need to have their learning disabilities demystified so that they can understand themselves. If parents have a clear understanding of their child's strengths and weaknesses, and there is support for the parent in the teaching process, progress can be made. At the same time, educational specialists, neuropsychologists and teachers need to closely monitor parents and children with learning disabilities to determine what is working and what is not working. Back-up plans are essential to deal with learning problems, and it should be emphasized that mistakes are not only accepted but are expected.

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What are researchers learning about the nature and treatment of learning disabilities? What research looks most promising?

Cheryl Weinstein, Ph.D.: It would take volumes of data to answer this question. The most important thing we know today is that "learning disability" is not a unitary term. There are multiple learning disabilities and multiple etiological factors, including genetic contributions. For example, when it comes to the genetics of ADHD, Joseph Biedermen of Massachusetts General Hospital reports that genes have only a small effect, with no one gene causing ADHD. It is more likely that genes, combined with environmental factors, can ultimately lead to the expression of attentional deficits.

We can now say with more certainty that it is essential to have a thorough assessment for each suspected diagnosis of learning disability. The "one size fits all" model does not work. It is clear that multiple tailored interventions are essential and should include parent and teacher training. We also know that learning disabilities cannot be "outgrown" and that a long-term perspective is necessary to better understand learning disabilities. For example, once a young adult with a learning disability graduates from college, new plans must be put in place for the work environment. After all, work requires reading, writing, and executive functions (planning, organization, prioritization, etc.).

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