Part 1: What are learning differences?

The relationship to the brain, treatment, reasons why you should care, and more!

If you haven’t yet, check out the Season 2 “teaser” as it level-sets on the definition of learning differences (LDs), this season’s scope, and the distinction between LDs and ADHD.

How do LDs impact the brain?

LDs are a brain-based condition impacting how one processes information, so let’s start with the brain! The brain is comprised of the cerebrum, cerebellum, and brainstem, and the cerebrum has four lobes, which control different functions as laid out below:

Graphic 1: Breakdown of brain lobes by core function[1]

Lobes are “designated” for specific functions, but ultimately, lobes work together to think, learn, move, etc. Some lobes play a larger role than others in reading, writing, or doing math most efficiently, and ultimately, LDs are developed when someone “under-activates” the lobes that are most efficient for reading, writing, and/or math and “over-activates” the less efficient lobes to compensate. If you think of lobes as “muscles”, the under-activated lobes become underdeveloped because, for reasons out of one’s control (discussed below), those muscles were not “exercised” enough.

For example, the parietal lobe is essential in calculating and processing numbers while the frontal lobe helps recall numerical knowledge[2]. A child with dyscalculia may rely on memorizing multiplication tables rather than understanding multiplication conceptually, and as a result, their brain would under-activate the parietal lobe, which is used to properly process numbers, and over-activate the frontal lobe to compensate and facilitate the memorization.

What causes LDs?

Why does someone struggle to activate the right lobes? That is just how their brain works and is primarily explained by genetics or environmental factors (e.g., trauma, prenatal/neonatal risks like premature birth).

• Genetics: Human genomes have ~20,000 genes, one-third of which are in the brain. These genes influence brain development and function, controlling how we move, think, feel, etc.[3] A phenotype is the set of observable characteristics determined by one’s genes and environmental factors (e.g., genes determining eye color). Genetic variants in the brain together can lead to phenotype variation where genes adversely impact reading and mathematical ability[4].

• Environmental factors: Environmental factors can hamper one’s ability to “exercise” the proper lobes. For example, when facing psychological trauma, the brain activates the amygdala (part of the temporal lobe) to manage stress[5]. If learning math while facing trauma, one’s brain would then over-activate the temporal lobe and under-activate the parietal lobe. Over time, the parietal lobe becomes underdeveloped, and an LD forms.

How are LDs diagnosed[6]?

LD evaluations include family history review, educational history review, classroom observations, and various tests (i.e., IQ, academic). Diagnoses are made by a psychologist or neuropsychologist (i.e., specialist focused on the brain-behavior relationship).

Tests

IQ tests measure cognitive skills like perception (i.e., processing information we smell/touch/hear/etc.,) attention, memory, etc. whereas academic tests measure academic skills (e.g., ability to complete math problems) [7]. Common skills tested (listed below) may sound foreign, but the takeaway is that the psychologist/neuropsychologist select specific skills to “test within the test” based on the child’s presenting concerns.

• IQ Test – Woodcock Johnson Tests of Cognitive Abilities: Skills selected for testing may include Comprehension-Knowledge, Long-Term Retrieval, Visual-Spatial Thinking, Auditory Processing, Fluid Reasoning, Processing Speed, Short-Term Memory, Quantitative Knowledge, Reading-Writing Ability.

• IQ Test – Wechsler Intelligence Scale for Children (WISC)-V Test: Skills selected for testing may include Verbal Comprehension, Visual Spatial, Fluid Reasoning, Working Memory, and Processing Speed.

• Academic Test – Woodcock Johnson Tests of Achievement: Domains selected for testing may include Reading, Math, and Writing.

Graphic 2: Sample test questions[8],[9]

Test performance is assessed by comparing IQ test results to academic test ersults (i.e., LD may exist if IQ score is high and academic score is low) or by comparing academic test results to local/national averages[10].

Diagnosis[11]

There is no clinical consensus on the definition (and therefore diagnosis) of LDs. DSM-5-TR is probably most widely known, and its diagnostic criteria includes difficulties persisting for six months despite intervention, academic skills substantially below expectations, and impairment that interferes with academic performance or daily living.

Determining whether one’s challenges meet said criteria is more art than science as psychologists/neuropsychologists consider family history, classroom history and observations in addition to test performance before officially diagnosing.

How are LDs treated?

Since the brain becomes less ‘malleable’ with age, children deeply benefit from early intervention (even prior to testing). Interventions include informal accommodation (e.g., allowing voice-to-text technology) or adjustments to standard general education to address needs (e.g., modifying assignments to have less problems). If these tactics do not generate progress, students will require the formal evaluation (discussed above) to determine need for more specialized instruction.

Approaches to special education

In 1-on-1 or small group settings, instructors (either special education teachers or educational therapists) deliver instruction by blending the following approaches[12]:

• Direct Instruction: Evidence-based, specialized approaches (e.g., Orton-Gillingham Approach for dyslexia) using multisensory (i.e., see/hear/touch/movement) techniques to teach a skill. For example, to teach the letter “G”, instructors might 1) show student the letter and have them recite the sound, 2) verbally make the “G” sound (“guh”) and have students write the letter in a plate of sand, and/or 3) have student say sound “G” in mirror and while touching their vocal chords.

• Strategy Instruction: Processes and tactics to help students approach learning more systematically. Strategies might include reminding oneself to check for spelling errors or using mnemonics to support memorization (PEMDAS for order of operations, anyone?!)

Chart 1 below highlights how LDs have unique focus areas necessitating different approaches to instruction.

Chart 1: Instruction focus areas and approach by LD (non-exhaustive)[13],[14]

Additional details on tactics used for reading and writing/math can be found here and here, respectively.

Why should you care?

Whether an entrepreneur, investor, operator, clinician, etc., I believe there are meaningful reasons to learn about LDs.

LD trickle-down effect: Failure to properly treat and manage LDs causes adverse effects across multiple dimensions.

• Education: Students with LDs are more likely to drop out of school. A 2014 study (older, but best I could find) by the National Center for Learning Disabilities (NCLD) claimed 18.1% of students with LDs dropped out of high school, nearly three times the rate of all students (6.5%)[15]. Dropping out has negative effects on employment, lifetime earnings, incarceration risk, and physical health[16].

• Mental health: LDs improperly treated can cause anxiety, depression, and low self-esteem. In an interesting study of ~200 11-12 year old (albeit Arabic language speakers), 82% of dyslexic students had “Low to Very Low” self-esteem and 73% had “Severe” or “Very Severe” anxiety compared to 17% and 19%, respectively, of non-dyslexic students.

• Physical health: LD impact on physical health is hazier, but LDs seem to significantly affect sleep. This study found that sleep disorders were more frequent in children with dyslexia than those without it.

Graphic 3: Learning difference trickle-down effect[17],[18]

Post-COVID tailwinds: Second order effects of disruptions to in-person activities during COVID have created a more favorable operating environment for LD-focused companies to emerge.

• Funding: In July 2021, concerned the lack of in-person learning would have an outsized impact on students with LDs, the U.S. Department of Education released more than $3B in funds to “support children with disabilities”[19], $2.5B+ of which went to states to provide special education[20]. Theoretically, more fundings means more resources available for evaluations (cities like NYC have begun implementing screening programs) which means less missed diagnoses which means more demand for special education!

• De-stigmatization: Back in 2017, an NCLD study found 33% of educators viewed some LDs as “laziness” while 43% of parents didn’t want others to know about their child’s LD[21]. Today, the LD stigma may still exist but is materially changing. First, the mental health stigma was largely reduced during COVID, and LDs benefit from broader acceptance of neurological conditions. COVID also let parents observe their children’s behavior firsthand (and see how they struggle), pushing parents to research ways to support their children’s learning. De-stigmatization means more awareness, discussion, and research, which could eventually provoke payers to cover special education (and create a paradigmatic shift as a result).

Parting shot

My primary goal for Season 2 is to spread awareness about LDs within the healthcare community. Given the LD trickle-down effect, it’s a high leverage opportunity to improve well-being, and since we are still in the early days of de-stigmatization, now could be a great time to start thinking about building in the space.

Last, I acknowledge LDs are a less traditional healthcare topic than ESRD, but if you stick around for the rest of Season 2, I promise it will be worthwhile!

**

Links to: Sources | Graphics (PPT)

If you want to chat further about LDs, follow me on Twitter @z_miller4 or connect with me on LinkedIn!

If you are an early-stage startup and potentially interested in my support for any unit economics or financial modeling-related activities, please fill out the form here.