The Adult lVith Learning Disabilities Where Do All the Children Go? Sharon A. Cermak, EdO, OTR/L, FAOTA Associate Professor of Occupational Therapy Director, Neurobehavioral Rehabilitation Research Center Boston University, Sargent College Faculty Member Emen'tis Sensory Integration International Torrance, California

Elizabeth Murray, SeO, OTR/L Assistant Professor of Occupational Therapy Research Associate, Neurobehavioral Rehabilitation Research Center Boston University, Sargent College Assistant Director of Occupational Therapy Shriver Center Waltham, Massachusetts Faculty Member Emeritis Sensory Integration International Torrance, California

Work and leisure are central activities to an adult. As an occupational therapy performance area, work includes "home management, caregiving, educational and vocational activities and retirement planning."1 As therapists working with school-aged children and adolescents with learning disabilities, we want to prepare them for their future roles as workers. This article focuses on the needs of the adult with learning disabilities. By better understanding the work-related problems of the adult with learning disabilities, we can more effectively

This paper was completed under the auspices of the Neurobehavioral Rehabilitation Research Center, a center for scholarship and research in occupational therapy funded by the American Occupational Therapy Foundation and the American Occupational Therapy Association.

design intervention strategies for the child and adolescent and, therefore, prevent many of the difficulties currently described by these adults. This approach may be viewed as analogous to industrial rehabilitation in which a major focus of intervention is prevention of injury or disability. In industrial rehabilitation, however, the focus of prevention is often on physical (musculoskeletal) injury, whereas the needs of individuals with learning disabilities are in a different domain.

LEARNING DISABILITIES: THE DEFINITION The term learning disabilities refers to individuals with normal intelligence who have difficulty with academic performance. Learning disabilities have been described by the U.S. Office of Education in the following manner: Children with specific learning disabilities exhibit a disorder in one or more of the basic psychological processes involved in understanding or using spoken or written language. These may be manifested in disorders of listening, thinking, talking, reading, writing, spelling or arithmetic. 2

Although the above definition is the legal definition, learning disabilities have been defined in many different ways. Three factors have consistently appeared: (1) there is a discrepancy between ability and academic achievement such that the student is not performing in school as well as would be expected based on his or her given intelligence; (2) the presumpWORK 1992; 2(2):41-47 Copyright © 1991 by Andover Medical Publishers, Inc.

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tion of central nervous system dysfunction; and (3) the limitation that the learning problems cannot be the result of mental retardation, emotional disturbance, environmental deprivation, or sensory or motor disability. The most commonly recognized deficits in children are those that pertain to academic success, with attention most often given to the reading and language deficits. However, there are nonverbal deficits in abilities such as spatial perception and motor coordination that also are important. In addition, individuals with learning disabilities often have associated hyperactivity, impairments in attention, and general maladaptive behavior. Students diagnosed as having a learning disability currently make up the largest percentage of enrollment in special education programs. 3 The incidence of children with learning disabilities is estimated to be from 1-30 % of the school population, depending on the criteria used to determine the disability,3-6 and the number of individuals receiving services for learning disabilities has been increasing. 7

LEARNING DISABILITIES IN ADU LTS The term learning disabilities no longer refers just to children. There is also an increased awareness of the continuing needs of adults with learning disabilities, and it is now recognized that a learning disability may impact on employment as well as education. The definition of learning disabilities proposed by the Association for Children and Adults with Learning Disabilities (ACLD) states that throughout life, the condition can affect education and vocation, as well as self-esteem, socialization, and! or daily living activities. s In 1985, a position paper by the National Joint Committee on Learning Disabilities stated that learning disabilities are "both persistent and pervasive throughout an individual's life,"9 although it emphasized that the manifestations of the learning disability change throughout the life span. For example, a student diag-

nosed as having a deficit in word recognition skills in second grade may be diagnosed as having a reading comprehension problem in seventh grade. A student described as hyperactive in second grade may be described as socially maladjusted as an adolescent. Several investigators have examined the continuing effects of learning disabilities. The social and behavioral, as well as the cognitive and perceptual-motor, manifestations will first be discussed since continuing problems in these areas impact on the vocational performance of the individual with learning disabilities. Vocational outcomes and daily living skills of the adult with learning disabilities will then be presented.

Social and Behavioral Manifestations Social Interaction. Several studies have identified a variety of social difficulties experienced by adults with learning disabilities. Key problems include affective deficits and social imperception leading to significant communication difficulties. lo- 12 White and colleagues found through self-report that individuals with learning disabilities were less active in social, fraternal, and recreational activities than their non-learning disabled peers. 13 Problems with social adjustment have been supported by several studies. On a self-rating scale, young adults with learning disabilities perceived themselves to be less socially and emotionally adjusted than control subjects. 14 In a survey of adults with learning disabilities, 17 % reported problems in making and keeping friends. However, 29% of the service providers and 50 % of all adults surveyed reported that this was a problem. Bruck found that subjects with learning disabilities reported loneliness and few social contacts, and in an ACLD survey of 562 adults with learning disabilities, the area that was ranked highest in terms of desire .for assistance involved social skills training. 15-17 In separate studies by Bruck and Spreen, females with learning disabilities showed the poorest adjustment. 15 •IS Moreover, in a review of four follow-up studies, Bruck reported that adults with learning disabilities

The Adult with Learning Disabilities

were more likely to show adjustment problems than normal peers and that severity of the learning disability was not related to measures of social and emotional adjustment. 16 Attention and Activity. Follow-up studies of hyperactive children indicate that while hyperactivity itself decreases as children get older, other problems emerge. In a longitudinal study, Hoy et al. found that at adolescence, although the activity declined, hyperactive children still had attentional and stimulusprocessing difficulties that affected both their academic and social functioning. 19 A survey by Hoffman and colleagues indicated that impulsivity (talking or acting before thinking) continues to be a problem. 20 The presence of deficits in this area is consistent with the results of a survey conducted by the ACLD Vocational Committee. 8 Self-Concept and Self-Esteem. Learning disabilities appear to have a persistent effect on self-concept and self-esteem. Studies of adolescents with learning disabilities or hyperactivity have found that 40-60 % have low selfesteem. 21 In a study of adults with learning disabilities, Hechtman, Weiss, and Perlman found that adults with learning disabilities manifested poor self-esteem and related low scores on social skills. 22 In addition, depression, thoughts of suicide, and low expectations for the future also are seen more frequently among disabled learners. II Cognitive and Perceptual-Motor Manifestations Cognition and Cognitive Style. Cognitive factors, such as attention, memory and retrieval, expression and comprehension of language, and the ability to organize complex information and perceive relationships, are needed to appriase situations accurately and to select and implement coping strategies. 23 While there have been few longitudinal follow-up studies, there have been several studies examining these skills in the adult with learning disabilities. Blalock reported that of 80 young adults with learning disabilities studied, although none showed "casually recognizable

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deficits," 80% showed some type of oral language and/or auditory processing deficit that was evident during extended conversation. 24 Blalock emphasized that these communication difficulties had resulted in social and vocational problems for the adults. Several investigators have studied memory and attention in adults with learning disabilities. Of the various cognitive problems listed on a survey sent to adults with learning disabilities and to service providers of adults with learning disabilities, memory difficulties were checked by the largest number of adults (30% ).20 Worden, Malmgren, and Gabourie reported that long-term recall in adults with learning disabilities was comparable to that of third graders, with recall being accurate but incomplete. 25 Perceptual Skills. Until recently, several researchers have suggested that perceptual problems were not characteristic of the older child or adult with learning disabilities. 26 In fact, Satz, Taylor, Friel, and Fletcher suggested that, while visual-perceptual problems were characteristic of young children with learning disabilities, conceptual-linguistic skills were more likely to be impaired in older children since these were "age-appropriate primary ascendant skills. 27.28 Rourke has recently drawn attention to the adult with learning disabilities whose patterns of deficits are characterized by poor visual-perceptual abilities and has suggested that this type of learning disability does not "disappear" or "change into a linguistic pattern" with age. II Neuromotor and Motor Performance. Although the Committee on Children with Disabilities of the American Medical Association stated that motor disabilities of children with learning disabilities generally improve over time without intervention, there have been several studies that would indicate that individuals with learning disabilities continue to have motor deficits. 29 In a longitudinal study, Shafer, Stokman, Shaffer, and colleagues found that adolescent males in the learning disabled group with minor neurological dysfunction continued to show more evidence of minor neurological dysfunction, including motor slowing.30 Cer-

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mak and colleagues compared the motor performance of students with learning disabilities 16-19 years of age to a matched control group.31,32 These authors found that students with learning disabilities showed poorer performance on tasks of bilateral motor coordination than did controls. In addition, a subgroup of the students with learning disabilities evidenced a higher incidence of mirror movements, and these neuromotor signs were associated with poor fine motor skills. Adolescents with learning disabilities are often aware oftheir motor deficits. In a self-report inventory, students with learning disabilities identified significantly more problems with aspects of motor abilities, including fine motor skills, ocular control, and copying skills, than did normal students. 33 There has been little research to examine the persistence of motor deficits in adults with learning disabilities, although there is certainly anecdotal evidence of continued motor problems interfering with leisure and occupation. 34 Knuckey and Gubbay followed up both clumsy and nonclumsy students 8-12 years of age to 24 years of age and found that, although there was evidence of improvement, there were continued differences between the groups.35 In a survey of adults with learning disabilities who were receiving vocational rehabilitation services, 16% reported problems with fine motor skills, as manifested by difficulty in handwriting. 20

Activities of Daily Living and Vocation Activities of Daily Living. Hoffman and associates surveyed adults with learning disabilities, their parents or other advocates, and their service providers on a variety of issues related to activities of daily living as well as vocation and social skills. 20 In one portion of the survey, all three groups were asked to check problems that the adult with learning disabilities was having with daily living skills. The items selected most frequently by all three groups involved handling money and banking. Driving was also identified as a major concern

of the adults with learning disabilities. Service providers and parents/advocates identified that the adults with learning disabilities had difficulty keeping track of time, although a much smaller percentage of adults with learning disabilities themselves identified this as a problem. Although self-care skills such as shopping, cooking, and housekeeping were not frequently reported as problems by the adults with learning disabilities, it must be noted that a large percentage of subjects surveyed lived at home with their parents and often were not required to perform independently. In fact, the parents/ advocates and service providers identified "dependence" as a major problem for the adults with learning disabilities. 20 Vocational Activities. Completion of educational preparation is necessary for many vocations. However, "a large number of adolescents with learning disabilities do not complete high school. Still other individuals have difficulty gaining admission to or completing postsecondary education programs including college or vocation preparation courses."g Although Bruck reported that a large proportion of individuals with learning disabilities enter a college program, their educational experiences are not similar to those of nondisabled students. 16 Rather, these college students work extremely hard to function in a university program and experience particular difficulties in reading complex prose, writing technical reports, and taking timed exams. A high proportion of students with learning disabilities require additional years to complete their college or university program. Although occupational outcome and employment rates vary from one study to another, several follow-up studies report poorer occupational adjustment and achievement among adults with learning disabilities. 18 ,36,37 In an ACLD survey of 562 adults with learning disabilities, the need for career counseling ranked second out of 10 needs. 8 Based on a study of the vocational adjustment of 50 young adults with learning disabilities and 50 non-learning disabled young adults, White reported that although an equal proportion of learning dis-

The Adult with Learning Disabilities

abled and normal young adults were employed and distribution of income was similar, the adults with learning disabilities were employed in jobs with significantly lower socioeconomic status than the controls, and adults with learning disabilities expressed significantly greater dissatisfaction with their employment situation relative to the controls. 38 Similar results were noted in a survey by Chesler. 17 In reference to occupational concerns of adults with learning disabilities, Blalock and Dixon noted that "fear of new situations, founded on a history of rejections and failures, may lead them to opt for less threatening but potentially less satisfying directions without full awareness of all possible consequences. "10

IMPLICATIONS FOR WORK PROGRAMMING FOR THE CHILD AND ADOLESCENT WITH LEARNING DISABILITIES Although many adults with learning disabilities are successful, many are not. The finding of significant vocational adjustment problems in the adult with learning disabilities suggests that work-related programming should be initiated at an early age. In fact, in a position paper, the National Joint Committee on Learning Disabilities stated that "throughout the school years, individuals with learning disabilities

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must have access to a range of programs and service options that will prepare them to make the transition from secondary to postsecondary or vocational training settings."9 They stated that in addition to continued emphasis on remediation of basic academic skills, provision of adaptive curricula, and enhancement of study skills, it is critical to facilitate development of "social and interpersonal skills as well as employable skills" and emphasized that "vocational programs should be initiated during the early school years."9 Jacobs has presented a model for introducing a work-related skills training program beginning in elementary school. 39,40 She applies work-related occupational therapy programs to various pediatric and adolescent populations, including the child with learning disabilities. Jacobs uses a theoretical framework in which activities are presented in sequential order based on the hierarchical stages of play specified in the occupational behavior approach: exploratory play, competency behavior, and achievement. Jacobs emphasizes that, in addition to developing specific technical skills, it is imperative to develop coping skills and abilities, enhance decision-making processes, and foster work-related behaviors and habits. By providing students with learning disabilities with a program that includes a work-related focus early in the school years, it is hoped that we can facilitate their transition to the role of worker as an adult.

REFERENCES 1. American Occupational Therapy Association: Uniform Terminology for Occupational Therapy, 2nd ed. Am] Occup Ther 1989; 43:808-815. 2. Brown JS, Zinkus PW: Screening techniques for early intervention. In Gottlieb MI, Zinkus PW, Bradford LJ (eds), Current Issues in Developmental Pediatrics: The Learning-Disabled Child. New York: Grune & Stratton, 1979, pp 315342. 3. Adelman HS, Taylor L: An Introduction to Learning Disabilities. Glenview, IL: Scott Foresman, 1986.

4. Lerner J: Children with Learning Disorders. Boston: Houghton Mifflin, 1976. 5. Sahler OJ, Levine MD, Schmitt BD: Learning disorders and the hyperactive child: The pediatrician's role. In Smith DH, Hoekelman RA (eds); Controversies in Child Health and Pediatric Practice. New York: McGraw-Hill, 1981, pp 404-440. 6. Zinkus PW: Behavior and emotional sequelae of learning disorders. In Gottlieb MI, Zinkus PW, Bradford LJ (eds), Current Issues in Developmental Pediatrics: The Learning-Disabled Child.

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New York: Grune & Stratton, 1979, pp 183218. 7. Keller C, Hallahan D: Learning Disabilties: Issues and Instructional Interventions. Washington, DC: National Education Association, 1987. 8. Association for Children and Adults with Learning Disabilities: ACLD vocational committee survey of learning disabled adults: Preliminary report. ACLD Newsbriefs 1982; Sept/ Oct:10-13.

21. Stewart MA, Mendelson WB, Johnson NE: Hyperactive children as adolescents: How they describe themselves. Child Psychiatry Hum Dev 1973; 4:3-11. 22. Hechtman L, Weiss G, Perlman T: Hyperactives as young adults: Self-esteem and social skills. Can] Psychiatry 1980; 25:478-482. 23. Polloway E, Smith J, Patton J: Learning disabilities: An adult development perspective. Learn Disabil Q 1984; 7:179-186.

9. The National Joint Committee on Learning Disabilities: Adults with Learning Disabilities: A Call to Action. A position paper of the National Joint Committee on Learning Disabilities, February 10, 1985. Baltimore, MD: The Orton Dyslexia Society, 1985, pp 172-173.

24. BlalockJW: Persistent auditory language disorders in adults with learning disabilities.] Learn Disabi11982; 15:604-609.

10. Blalock G, Dixon N: Improving prospects for the college-bound learning disabled. Top Learning Learning Disabil1982; 2:69-78.

26. Geschwind N, Galaburda A: Cerebrallateralization. Arch Neuro11985; 42:428-459.

11. Rourke B: Non Verbal Learning Disabilities: The Syndrome and the Model. New York: Guilford Press, 1989. 12. Smith CR: Learning Disabilities: The Interaction of Leamer, Task, and Setting. Boston: Litde, Brown & Co, 1983. 13. White WJ, Alley GR, Deshler DC, et al: Are there learning disabilities after high school? Excep Childr 1982; 49:273-274. 14. Peter BM, Spreen 0: Behavior rating and personal adjustment scales of neurologically and learning handicapped children during adolescence and early adulthood: Results of a followup study.] Clin Neuropsych 1979; 1:75-92. 15. Bruck M: The adult functioning of children with specific learning disabilities: A follow-up study. In Siegel I (ed), Advances in Applied Developmental Psychology. Norwood, NJ: Ablex, 1985, pp 91-129. 16. Bruck M: The adult outcomes of children with learning disabilities. Ann Dyslexio.1987; 37:252263. 17. Chesler B: ACLD vocational committee completes survey on LD adult. ACLD Newsbriefs 1982; 146(5):20-23.

25. Worden P, Malmgren I, Gabourie P: Memory for stories in LD adults.] Learn Disabil 1982; 15:145-152.

27. SatzP, TaylorHG, FrielJ, FletcherJM: Some developmental and predictive precursors of reading disabilities: A six-year follow-up. In Benton AL, Pearl D (eds), Dyslexia: A Critical Appraisal Of Current Theory. New York: Oxford University Press, 1978, pp 313-348. 28. Spreen 0, Haaf R: Empirically derived learning disability subtypes: A replication attempt and longitudinal patterns over 15 years.] Learn Disabi11986; 19(3):170-180. 29. Committee on Children with Disabilities: School-aged children with motor disabilities. Pediatr 1985; 78: 185-186. 30. Shafer SQ., Stokman CJ, Shaffer D, et al: Tenyear consistency in neurological test performance of children without focal neurological defect. Dev Med Child Neuro11986; 28:417-427. 31. Cermak S, Trimble H, CoryellJ, et al. Bilateral motor coordination in adolescents with and without learning disabilities. Phys Occup Ther Pediatr 1990; 10(1):5-18. 32. Lebby M: Incidence of Mirror and Overflow Movements in Learning Disabled and Normal Young Adults, Master's Thesis. Boston: Sargent College, Boston University, 1988.

18. Spreen 0: Prognosis of learning disability. ] Consult Clin Psychol 1988; 56:836-842.

33. Whyte LA: Characteristics oflearning disabilities persisting into adolescence. Alberta] Educ Res 1984; 30:14-25.

19. Hoy E, et al: The hyperactive child at adolescence: Cognitive, emotional and social functioning.] Abnorm ChildPsychol1978; 6:311-324.

34. CermakS, Henderson A: Learning disabilities. In Umphred D (ed), Neurological Rehabilitation. St Louis, MO: Mosby, 1990, pp 283-331.

20. Hoffmann FJ, Sheldon K, Minskill E, et al: Needs oflearning disabled adults.] Learn Disabil 1987; 20(1):43-52.

35. Knuckey NW, Gubbay SS: Clumsy children: A prognostic study. Austral Paediatr] 1983; 19: 9-13.

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36. FinucciJ, Gottfredson LS, Childs B: A followup study of dyslexic boys. Ann Dyslexia 1985; 35: 117-136.

39. Jacobs K: Occupational Therapy: Work-Related Programs and Assessments. Boston: Little, Brown & Co, 1985.

37. Spreen 0: Learning Disabled Children Growing Up: A Follow-Up Into Adulthood. Victoria, BC: University of Victoria, 1983.

40. Jacobs K, Logigan M: Learning disabilities. In Jacobs K, Logigan M (eds), Pediatric Rehabilitation. Boston: Little, Brown & Co, 1989, pp 95154.

38. White WJ: Perspectives on the education and training of learning disabled adults. Learn Disabil Q 1985; 8:231-237.

The Adult with Learning DisabilitiesWhere Do All the Children Go?

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