Learning
Disability:
10-Year
Follow-up
Harry
E.
Hartzell,
MD, and Carolyn
Compton,
PhD
From the Department of Pediatrics, Stanford Medical School, and Palo Alto Medical Clinic, The Children’s Health Council, Palo Alto, Califonia
ABSTRACT. A 10-year follow-up of 114 learning-disabled students has been conducted, gathering information on their academic achievement, social success, and job sat-isfaction. These students have been compared with 144 siblings without learning disabilities. Significantly lower levels of school attainment, academic success, and social success are found for the learning-disabled group. No difference is found in level ofjob satisfaction. Significant positive factors contributing to school success in the learning-disabled group were high IQ, less severe learning disability, positive personality characteristics in the child, effective family function, strong family support, high occupational level of family breadwinner, and high edu-cation level attained by the mother. Negative factors are a more severe degree of learning disability, the presence of hyperactivity, and a concomitant disability in mathe-matics. Pediatrics 1984;74:1058-1064; dyslexia, learning disability.
A retrospective study was made of 1 14 learning-disabled students, 10 years after a comprehensive evaluation determined their disability. The learn-ing-disabled students’ academic achievement, so-cial adjustment, and job experience have been com-pared with those of their siblings without learning disabilities. Statistical analyses were used to deter-mine characteristics of the students and their fam-ilies at the time of evaluation that related to
suc-cessful outcomes.
HISTORICAL BACKGROUND
The nature of learning disabilities, their diagno-sis, and therapy have been well descnibed’4 for
school-aged children. It has been shown that the perceptual problems5 and the reading and spelling disabilities6 persist into young adulthood. A recent study of graduates from a private high school for learning-disabled boys found a significantly lower
Received for publication Nov 21, 1983; accepted Feb 13, 1984. Reprint requests to (H.E.H.) Palo Alto Medical Clinic, 300 Homer Aye, Palo Alto, CA 94301.
PEDIATRICS (ISSN 0031 4005). Copyright © 1984 by the American Academy of Pediatrics.
proportion in the professions when compared with control subjects from a private school of similar socioeconomic stratum.7 A recent review of long-term follow-up studies8 indicated the need for stud-ies that control such factors as socioeconomic status and age, and provide data from a control group.
MATERIALS AND METHODS
Charts of 223 children evaluated at a nonprofit diagnostic clinic between 1970 and 1973 were ran-domly selected; a thorough search located 114 stu-dents whose families agreed to participate in the study. Questionnaires were sent to each family to obtain current information about the student; tel-ephone interviews were used when questionnaires were not returned. The data were collected from 33 completed questionnaires, 81 telephone interviews, and 20 personal interviews with students. Similar data were obtained for 144 siblings without learning disability.
POPULATION
The evaluation for learning disabilities was pen-formed at The Children’s Health Council by a team of professionals consisting of a social worker, psy-chologist, pediatrician, occupational therapist, speech and language therapist, and learning disa-bility specialist. The testing procedures used were
those common in the field in the early 1970s: the
Wechsler Intelligence Scale for Children (WISC), the Bender Visual Motor Gestalt Test, the Wide Range Achievement Test, other standardized tests of academic achievement, the Illinois Test of
Psy-cholinguistic Abilities, and other measures of
lan-guage skills. Projective testing, motor evaluations, neunologic examination, and other procedures were included when appropriate. Every family was inter-viewed to obtain early history and the family’s view
of
the problem. The 114 students in the study all had primary diagnoses of learning disability, whichis usually defined as a discrepancy between
TABLE 1. Characteristics and Data of 114 Learning-Disabled Students
N % Mean ± SD Range
82!32 72!28 6 3 104 1 5 3 91 1 15-27
TABLE 2. Family Characteristics
N % 97 85 67 80 75 74 55 53 22 19 17 26 23 64 58 29 26 51 45 32 28 53 68 25 32 Sex (M!F) Race Black Hispanic White Oriental Age (yr)
Follow-up time (yr)
Wechsler Intelligence Scale for Children (WISC) scores (N
= 86) Verbal IQ Performance IQ Full-scale IQ
Type of learning disability
Auditory
Visual Mixed
Severity of learning disability Mild
Moderate Severe
Estimate of psychosocial func-tioning Low Average High Hyperactivity Yes No 10 9 38 33 66 58 25 22 50 44 39 34 49 44 47 42 16 14 24 21 90 79
19.3 ± 2.8
9.6± 2.6
107 ± 16.5
108 ± 16.0 107 ± 15.2
70-150
67-147 74-151
deficit in one or more psychological processes such as attention, memory, or perception. Children with
mental retardation or primary emotional disturb-ance were excluded from the study.
The population characteristics are presented in Table 1. At the time of evaluation the children ranged in age from 5 to 15 years, mean 8.5 years. On the WISC, they demonstrated a wide range of intellectual ability with a mean full-scale IQ of 107 for the group. The population was 72% male, and
91% were white. A measure of the degree of disa-bility was determined for each student by combin-ing three equally weighted factors. These factors were: (1) the number of years below grade level the student was reading, (2) the number of academic
areas affected, and (3) the number of modalities
involved, that is, visual, auditory, and kinesthetic. Within the group, 22% were described as mildly
disabled, 44% as moderately disabled, and 33% as
severely disabled. Using a combination of the pen-ceptual tests administered, their learning disabili-ties were described as primarily auditory (9%), pni-manly visual (33%), on mixed (58%). “Primarily auditory” can be interpreted to mean a consistent pattern of low scores on auditory tests with strong performance on visual tests; the opposite pattern was termed “primarily visual.” Most students
dis-Intact family
History of learning disabilities College degree: father College degree: mother
Parents occupation (Hollingshead scale) Unskilled (0-1)
Skilled (2-3)
Small business, engineer (4-5) Manager, professional (6-7) Estimate of family functioning
Low
Medium
High
Estimate of family support Positive
Negative
played an inconsistent on “mixed” pattern.
intact. A family history of learning disabilities was reported in 80% of the families.
ADDITIONAL MEASURES
In addition to descriptive data for each child and family, the old charts were reviewed by two
inde-pendent raters and given a rating on two composite
variables, family functioning and psychosocial
functioning of the child. Family functioning (Table 2) was measured on a three-point scale rating the
quality of the overall family functioning at the time
of the evaluation. Families were rated as low if the
family life was described as chaotic and highly
stressful; an average rating was given when the
family was described as having some problems but coping effectively; high ratings were given to
fami-lies described as cohesive, supportive, and effective. Psychosocial functioning (Table 1) was evaluated on a three-point scale rating the child’s social func-tioning at the time of evaluation. Children were who were described as having no friends at school,
who had difficulties within the family and the
neighborhood, and who acted depressed on
with-drawn when interviewed were rated as low (44%). High ratings (14%) were given to children who were
described as having many friends and who appeared eager and cooperative. Children who did not fall at either end of the range were given an average rating
(42%).
Hyperactivity (Table 1) was determined by
con-sensus of behavior description by two of three
sources (parents, teachers, pediatricians) in the
original chart. Only 21% of the children met this criterion.
Family support (Table 2) was judged from the follow-up data by two independent raters and ad-judicated when necessary by a third. The support
was considered either positive (in the interest of
the child) on negative (at cross purposes to the child). The majority of our study children (68%) received positive family support.
TREATMENT
This study did not control the treatment of the children. In the 10 years between evaluation and follow-up, the children attended a wide variety of public school programs and received several forms of private tutoring on private school placement as well. Thirty-nine percent of the children were
ne-tamed in a grade, usually early in their schooling. Thirty percent of the children received special ed-ucation services, public or private, for less than 2 years; 37% participated in special programs for 2 to
6 years; and 33% needed special services throughout
their school careers. In addition, the majority had
some other modalities of treatment (Table 3).
TABLE 3. Treatment of Learning Disabilities
N %
Public school tutorial program 79 69 Public school learning-disabled class 27 24
Private tutoring 78 68
Private regular school 41 36
Private special education school 17 15 Total extent of treatment
<2yr 34 30
2-6 yr 42 37
Throughout school 38 33
Retained in grade
Yes 44 39
No 70 61
Speech therapy 35 31
Counseling 50 45
Parent counseling 44 39
Motor program 13 12
Medication 29 26
Diet 4 4
FOLLOW-UP DATA
At the time of follow-up, the average age of the learning-disabled students was 19 years, range 15 to 27 years. The mean length of time from
evalua-tion to follow-up was 9.6 years. Through question-name and telephone interview, parents were asked to determine each student’s current level of educa-tion, and to assess the student’s degree of academic, social, and employment success. Information was gathered about each student’s school and social experiences. We were interested in how each stu-dent and his or her family had been affected by the
student’s learning disability. Most families were eager to talk about the people and programs that had or had not been helpful.
No objective data were gathered, that is, the student’s school records were not reviewed, no
test-ing was done to obtain current academic skill levels,
and no information was sought from present
em-ployens. The outcome measures in this study are the perceptions of the parents and students about each student’s degree of academic, social, and job success.
Parents were also asked to rate academic success, social success, and job success for their children who did not have learning disabilities. The level of educational attainment was also recorded for these siblings without learning disabilities. The average age of the sibling (N = 144) group was 21.5 years (range 15 to 36 years). This group was 62% female.
RESULTS
16% 21% 15%
23%
47%
30%
62%
9% 6%
23%
31%
53% 16%
12%
46% 36%
75% 22%
3%
67% 13%
1%
19%
77% 20% 8%
TABLE 4. Educational Attainment and Academic, Job, and Social Success of
Learning-Disabled Students (LDS) and Their Siblings Without Learning Disabilities (Non-LDS)
LDS Non-LDS
(N = 114) (N = 144)
Age (yr) 19.3 (15-27) 21.5 (15-36)
Sex (M/’F) 82/32 55!89
(72%!28%) (38%,/62%)
9% 1%
35% 11%
Educational attainment* Dropped out of high school Did not continue past high
school (>age 17)
Attend junior college (> age 17) Attend college (> age 17) Graduated college (> age 21) Academic successt
High Medium Low Job success
High
Medium
Low
No job experience Social successt
High Medium Low
* P < .001, McNemar test of symmetry.
t P < .001, matched pairs t test.
Educational Attainment
Of the 1 14 learning-disabled students, 9% have
dropped out of high school compared with 1% of
the siblings who were not learning disabled. Of those graduating from high school, 35% of the learning-disabled group did continue with further
education, whereas only 11% of the group without learning disabilities stopped school after receiving
a high school diploma. Similar numbers of both
groups attended junior college.
Only 21 % ofthe learning-disabled group attended a 4-year college, compared with 46% of the group without learning disabilities. Of those more than age 21 years, 15% of the learning-disabled group
has graduated from college compared with 36% of
the control group without learning disabilities.
When age is controlled for, the difference be-tween the learning-disabled students and their sib-lings without learning disabilities is statistically
highly significant (P < .001, McNemar test of
sym-metry). When comparing the siblings by family group, the learning-disabled students avenge one
step lower in level of educational attainment.
Academic Success
Academic success was measured on a three-point scale rating. High academic success was defined as
having feelings of satisfaction with academic skills,
finding success in school work. Moderate success was defined as viewing school as difficult but tol-enable. Low success was defined as viewing school as a negative experience, a source of frustration. Twenty-three percent of the learning-disabled stu-dents experienced high academic success compared
with 75% of the sibling without learning
disabili-ties. This difference is statistically significant (P <
.001). Low academic success was described by 30% of the learning-disabled students but by only 3% of
their siblings.
Social Success
Social success was also measured on a three-point rating scale. High social success was defined as having many friends, leadership qualities, and the facility for interpersonal relationships. Low social
success was defined as having feelings of loneliness, isolation, and social awkwardness. Between the two
ratings were students who had moderate social suc-cess and a few close friends, but who were uneasy
in large groups. The difference between the
learn-ing-disabled students and their siblings without learning disabilities is also highly significant ( P <
and isolated compared with 8% of the siblings with-out learning disabilities.
Job Success
The learning-disabled student group is too young for conclusions to be drawn about job success; more than one third of the group is still in high school. Both learning-disabled students and siblings with-out learning disabilities have the same entry level jobs, such as working for fast-food chains, doing yard work, or babysitting. When asked to rate their job experiences from high to low (highly positive,
mixed, and negative) there was no statistical differ-ence between the learning-disabled students and their siblings without learning disabilities. Sixty-two percent of the learning-disabled group and 67% of their siblings reported high job success, and 6% of the learning-disabled group reported job failures compared with 1 % of the siblings.
Best Predictors of Success
Using stepwise multiple regression techniques, the data were analyzed to discover which variables at the time of evaluation were most predictive of academic, social, and job success 10 years later. These data are reported in Table 5. Effective family functioning and high full-scale IQ were the best predictive variables for high academic success, which together accounted for 35%. Full-scale IQ and the psychosocial functioning of the child were the best predictive factors for social success and accounted for 22%. Job success was best predicted by current age and full-scale IQ and accounted for
30%.
Correlational Data
The data were analyzed by correlational proce-dunes to determine which variables present in the child, in the family, and in the treatment were
individually related to positive outcomes in aca-demic, social, and job experiences (Table 6). Con-related factors are not, of course, causal factors and these tables should not be interpreted in that way. For example, an interest in sports does not cause a student to be academically and socially successful. Rather an interest in sports may be related to high self-esteem, which in turn may increase the proba-bility of academic and social success. Several of the same factors were found to be highly related to both academic and social success. Students with good intellectual ability, particularly in the verbal areas, were more likely to experience academic and social success. The educational level of the mother was
related positively to both outcomes whereas the
occupational level of the family breadwinner was related to academic success. Strong psychosocial functioning in the child, an effective functioning family, and a strong supportive family were key factors in both areas. An interest in sports on other outside-of-school activities related not only to so-cial success but also to academic success. Private tutoring, the only treatment variable associated with positive outcomes, was correlated more highly with social success than with academic success.
None of these variables was associated with job success; age, for obvious reasons, was. Interestingly, age at time of diagnosis was not related to either academic or social success; it was positively related to job success.
Factors individually contributing to negative out-comes (Table 7) were also determined. The degree of disability was the most significant contributor to lack of social and academic success. Placement in a special education full-day class, counseling for the child and family, and concomitant disabilities in
mathematics are all factors related to degree of
disability as is the presence of hyperactivity. Whereas disability in mathematics was not related to lack of job success, a disability in visual motor skills was.
TABLE 5. Variables Identifie
demic, Job, and Social Success
d Through Stepwise Regression as C in Learning-Disabled Students*
orrelate d with
Aca-Variable r F P R’
Academic success (N = 81)
Step 1 Family functioning .46 (112) 16.76 .001 .21
Step 2 Full-scale IQ .42 (88) 17.85 .001 .35
Job success (N = 78)
Step 1 Current age .38 (109) 16.69 .001 .17
Step 2 Full-scale IQ .16 (85) 4.39 .050 .22
Social success (N = 80)
Step 1 Full-scale IQ .35 (87) 13.57 .001 .20
Step 2 Psychosocial functioning .44 (111)
of child
10.64 .010 .30
* Values in parentheses after outcome variable are number of subjects with full set of
TABLE 6. Factors Correlated with High Academic, Social, and Job Success in Learning-Disabled Students*
Academic Social Job
Verbal IQ .40 (86) .34 (85)
Performance IQ .30t (86) .28t (85)
Full-scale IQ .42 (88) .35 (87)
Current age .38 (109)
Age at diagnosis .25t (109)
Psychosocial functioning .41 (112) .44 (111)
Occupational level .23 (111)
Education of mother .20t (104) .21t (103)
Family functioning .46 (112) .33 (111)
Family support .41 (109) .19t (108)
Private tutoring .28 (114) .35 (113)
Interest in sports .25t (112) .38 (111)
Other interests .19t (112) .271 (111)
* Values for each pair of variables are shown in parentheses.
tP<.05. 1:P< .01.
§P<.001.
TABLE 7. Factors Correlated with Low Academic, Social, and Job Success in Learning-Disabled Students*
Academic Social Job
Degree of disability .38 (114) .33 (113)
Special education class .32 (114) .25 (113) .22t (109)
Disability in mathematics .23t (114) .29 (113)
Disability in visual .23 (113)
motor skills
Counseling .28 (112) .33 (107) .23 (111)
Parent counseling .31 (112) .20t (107) .22t (111)
Hyperactivity .25 (114)
Medication .27 (112) .27 (107) .24 (111)
* Values for each pair of variables are shown in parentheses.
t P < .05. :j:P<.01.
§P<.001.
Type of disability, family intactness, and other treatment variables were not significantly related to outcomes in the three areas.
DISCUSSION
The effects of learning disabilities carry oven into young adulthood. This group of learning-disabled students is very different from their siblings with-out learning disabilities even though one might expect some learning-disabled characteristics in the siblings. Overall, they attain one educational level lower than their siblings and by their own percep-tions achieve significantly less academic and social success. In entry-level jobs, there is no difference between the groups in job success.
A successful outcome is most likely when the
child has a positive personality, when the family functions well, when the family is of high socioec-onomic status, and when the family is supportive of the child. The presence of a high IQ, a partici-pation in sports, and work experience in high school
contribute to a successful outcome. A guarded out-come is more likely when the learning disability is severe, when it is combined with disability in math-ematics, and when there is hyperactive behavior.
Several key factors were not related to outcome in our population. As independent factors, type of disability and family intactness were not related to
outcome. Age at diagnosis was not related to aca-demic on social success, suggesting that at least in this upper middle-class population intervention at older ages is still very effective. Retention in school did not contribute to a successful academic out-come. However, in our interview data, those stu-dents who had been retained in later years (sixth and seventh grades) were more positive about the
experience. They felt they knew why they were
being retained and had a role in the decision. Stu-dents retained in kindergarten and first grade con-tinued to recall it as a negative experience under-mining their confidence and self-esteem.
were not critical enough to compare treatment mo-dalities. In general, the more severe cases received
more treatment and did less well. Placement in a
special day class, a measure of severe academic disability or social problems, was negatively related to academic and social success. Private tutoring, a widely used intervention, was highly related to both academic and social success. In our interviews, the students reported that they liked private tutoring both because it was more individualized and more anonymous.
These adults are still very young and it is too early to evaluate their career success, but it is apparent that few of the learning-disabled group will graduate from college, and, therefore, entry into
the professions is unlikely.
It must be emphasized that this population of
learning-disabled students represents a favored mi-nonity. They are from highly educated families, with socioeconomic advantages, and receive a wide va-niety of special services. The academic experience
of this group cannot be extrapolated to the popu-lation at large.
IMPLICATIONS
For those medical and educational personnel who counsel parents of young children with learning disabilities, this research has important implica-tions. Parents need to know that learning disability
is a chronic disorder; it doesn’t become totally cured or remediated. Many students with learning disa-bilities require special services throughout their school careers, and the effects of the disorder are still seen in adulthood. If family means are avail-able, private tutoring seems to be a particularly helpful intervention, in part due to its anonymity. Students need a great deal of support and encour-agement as they deal with academic pressures and related social problems. Encouraging students to develop interests in out-of-school activities and fos-tening their strengths in nonacademic skills will
help them to achieve not only social success, but
academic success. Work experience in junior and
senior high school enables students to experience positive feelings of worth. Family expectations for the academic performance of a student with learn-ing disabilities should be realistic and based on a knowledge of the student’s IQ and degree of disa-bility. Vocational and career counseling are impor-tant interventions for the adolescent.
ACKNOWLEDGMENTS
This study was supported by a grant from the Amen-can Academy of Pediatrics’ Memorial and Endowment Fund for Children.
Dr Esther Clark and Dr Sheldon Woodward assisted in gathering and analyzing the data. Dr Helena Kraemen provided statistical advice and Professor Irving Schul-man provided support.
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