Diagnosis, which diagnosis? Pitfalls and prospects for supporting the struggling learner

Transcription

1 Diagnosis, which diagnosis? Pitfalls and prospects for supporting the struggling learner Susan Gathercole MRC Cognition and Brain Sciences Unit Learnus Lecture, May 17 th 2017

2 Educational under-achievement Some facts about under-achievement Some causes Learning difficulties are explained by dimensions rather than diagnoses Limitations of cognitive training Compensation not cure for struggling learners

3 Attainments in literacy and numeracy of 13- to 19-year-olds in England, % year olds have poorer literacy than required for full participation in society (functional levels at or below 11 year) 22% have poorer numeracy than required No significant changes in prevalence of these problems since 1980

4 PISA 2015: differences between highest and lowest achievers by country Maths Reading Science

5 PISA 2015: differences between highest and lowest achievers by country Maths Reading Science

6 Social inequity Gaps in cognitive development for children from disadvantaged backgrounds: Language Executive functions Attention Emotion regulation Long-term memory IQ

7 SES impact on learning scores: Feinstein et al. (2003) Average rank of test score Feinstein et al Age in months

8 SES impact on learning scores: Feinstein et al. (2003) Average rank of test score High SES Low SES High SES Low SES Age in months Feinstein et al. 2003

9 SES impact on learning scores: Feinstein et al. (2003) Average rank of test score High SES Low SES High SES Low SES Age in months Feinstein et al. 2003

10 SES impact on learning scores: Feinstein et al. (2003) Average rank of test score High SES High SES Low SES Low SES Age in months Feinstein et al. 2003

11 Response to Intervention approach (RTI) Tiered approach considered to be best practice: 1. Whole class: research-informed effective instruction 2. Small group: extra instruction, weekly monitoring and parental liaison 3. Intensive individual intervention: if progress not made, may be referred for special education support Some research-informed evidence: Early phonological training benefits literacy development, oral language training boosts language abilities (Bowyer-Crane et al., 2007) Phonological interventions for reading difficulties equally beneficial across a wide range of IQ (Elliott & Grigorenko, 2014)

12 Learning-related diagnoses Common diagnoses include: ADHD dyslexia/ reading difficulties dyscalculia/ mathematical difficulties language impairments ASD dyspraxia

13 Diagnoses are a good thing Aid to understanding underlying problems Help guide choice of effective intervention May attract much-needed addition intervention/ resource

14 The downsides of diagnosis These diagnoses are highly comorbid (20-80%) Many symptoms in common: problems in working memory, phonological processing, executive functions, inattention Symptom variability is very high for children with the same diagnosis Routes to diagnosis are haphazard Makes research into causes, symptoms and effecttive treatment very difficult

15 Cognitive and behavioural profiles of children with ADHD and low working memory Symptoms of ADHD inattention and hyperactivity low working memory broader impairment of executive functions predominance of males Symptoms of low WM educational under-achievement (reading, maths) low working memory inattention 60% male Holmes J, Hilton K, Place M, Alloway TP, Elliott J, Gathercole SE (2014). Children with low working memory and children with ADHD: same or different? Frontiers in Human Neuroscience, 8, 976

16 Holmes et al. (2014) Attentional behaviours in children with ADHD and low WM

17 Holmes et al. (2014): Learning and IQ in children with ADHD and low WM

18 ADHD and low working memory: two dimensions of cognition and behaviour? D1: Executive skills executive functions including working memory, planning attentional control (inattention) D2: Hyperactivity/ impulsivity Holmes J, Hilton K, Place M, Alloway TP, Elliott J, Gathercole SE (2014). Children with low working memory and children with ADHD: same or different? Frontiers in Human Neuroscience, 8, 976 doi: /fnhum

19 Do dimensions work better than diagnoses? CALM (Centre for Attention, Learning & Memory) clinic established in September 2014(460 children to date) Recruited children experiencing difficulties: from schools, educational psychologists, mental health services, clinical psychologists, paediatrians, speech and language therapists Assessed cognition, learning, brain structure, genes Asked: (diagnoses aside) What dimensions of cognition, learning, behaviour & brain structure distinguish these children?

20 CALM domains LEARNING Risks & causal factors C O G N I T I O N BEHAVIOUR BRAIN GENES Attention Episodic memory Executive functions Phonological processing Processing speed Nonverbal reasoning Working memory Executive functions, attention, communication Structural MRI, diffusion-weighted imaging, resting-state Saliva

21 Referral information Referrer n SENCo 268 Paediatrician 81 Clinical psychologist 30 Speech & language therapist 29 Specialist teacher 14 ADHD nurse practitioner 13 Educational psychologist 6 Family worker locality team 5 Child psychiatrist Diagnosis n ADD 8 ADHD 65 Possible ADHD 35 Hyperactivity 1 Dyslexia 30 Dyspraxia 13 Dysgraphia 1 Dyscalculia 0 FASD 5 Generalised delay 5 Social anxiety 1 Depression 2 Autism 25 PDA 1 Tourettes 4 DAMP 3 Anxiety 0 OCD 2 Speech & language 68 No diagnosis 297

22 Learning and cognitive skills: mean z-scores Learning Phonological processing Memory Fluid intelligence

23 Mean z-scores for deficit subgroups Voc, read & maths <86 Voc & maths <86 Read & maths <86 Read <86 Maths <86 All >

24 Age-typical learners All > Poor learners with and without reading difficulties Voc, read & maths <86 Voc & maths < Phonological retrieval and storage

25 Two dimensions of cognition, learning and behaviour

26 Two dimensions of cognition, learning and behaviour

27 Dimensions so far.. Cognition Behaviour Learning Phonological Reading, language Executive/ spatial Inattention Maths? Hyperactivity* Social/ pragmatic communication *Hawkins et al. (2015): dimension of hyperactivity and social pragmatic communication problems within and beyond ADHD, Brain Sciences, 6, 50

28 Is brain network organisation linked with maths and reading abilities? Joe Bathelt, Susan E. Gathercole, Duncan E. Astle Ms submitted for publication

29 Method Used graph theory to construct the white matter network structure from MRI scans Optimal network structure is high local connectivity (clustering, rich club nodes) with some long-range connections: small world organisation

30 The group structural connectome Brain regions = nodes Connections = edges (strength of white matter connectivity) Nodes shown in blue are members of the rich club (n=19)

31 Network structure was linked with learning Children with more efficient networks had better reading and maths scores Suggests changes in large-scale brain organisation more important during learning than highly specialised brain regions implicated in adult reading and maths.. possibly because multiple cognitive sub-systems involved

32 Cognitive training as an educational intervention Working memory (WM) is probably the best predictor of academic learning: can training it improve educational outcomes? Training boosts performance on similar WM tasks... but not on either different or already familiar WM tasks, or on associated learning abilities Propose* that trainees learn to do something new (a novel cognitive routine) during training This ability depends on general fluid cognitive abilities But it doesn t have any impact on basic WM capacity and therefore learning *Gathercole, Holmes, Dunning & Norris: WM training involves learning to do something new. In prep.

33 How does this help us the struggling learner? Dimensions of strengths and weakness add to (or maybe could be replace) conventional diagnoses Instruction should be guided by evidence: oral language and phonological abilities are modifiable at 4/5 years WM capacity is (probably) not Encourage children with persisting cognitive problems to develop compensatory skills and strategies: there s more than one way to learn

34 Thanks to: Joni Holmes, Head of CALM Duncan Astle Tom Manly Frankie Woolgar Sally Butterfield Joe Bathelt Erin Hawkins and all the CALM team