Table 2 Sample of 111 Children with Depression or Dysthymia Diagnosis n (%) Age (SD) Male Minority Special Education Depressed or dysthyrnic (only) 47 (42%) 10.2 (2.3) 67% 41% 21% Depressed or dysthyrnic (comorbid) 38 (34%) 10.9 (2.8) 68% 24% 44% Depressed or dysthymic (with LD) 26 (23%) 11.4 (2.7) 62% 31% 85%

Table 3 Consensus Summary of LD Subtypes Subtype Cognitive or Social Patterns Percent of LD Non-LD pattern Discrepancy from grade but not IQ Possible frustration, absences 25-38% Production deficits Inefficient cognitive strategies Possible inattention or hyperactivity 22-30% Verbal organization disorders Poor understanding or language use Possible aggression or acting out 14-17% Nonverbal organization disorder Visual-spatial-motor deficits Possible social misperception or withdrawal 11-15% Global disorders Multiple deficits in processing Possible problems in all coping skills 8-10% Note. Adapted from information in "Adaptive behavior of subtypes of learning disabled individuals," by C. Weller and S. Strawser, 1987, Journal of Special Education, 21, pp. 101-115.

Undoubtedly, when depression, attention deficit disorder or another problem occurs concurrently with a learning disability, the need for increased special education support comes to the fore. It should be noted that the same phenomenon occurred in a sample of 67 children with a primary diagnosis of conduct disorder when their secondary diagnoses included ADHD or depression and a learning disability (Forness, Kavale, & Lopez, 1993). As mentioned, it is not uncommon for ADHD and depression to overlap conduct disorder (Bird et al., 1993; Newcomer, Barenbaum, & Pearson, 1995).

LEARNING DISABILITIES SUBTYPES

Explorations of subtypes of children with learning disabilities may help clarify the nature of the relationship between learning disabilities and psychiatric diagnoses (Biederman et al., 1991). Indeed, a great deal of effort in the learning disabilities field has focused on developing more understandable or manageable types of disability based on different patterns of cognitive or psychologic dysfunction (Forness, 1990).

The goal of subtyping research is to divide heterogeneous samples of youngsters with learning disabilities into homogeneous groups based on patterns of performance across a variety of tests or other measurements thought to be critical to the development of learning disabilities. The numbers of subtypes found across various studies have ranged from 2 to 7, with anywhere from 1 to 32 different psychological or neurological measures being used to determine subtype patterns (Kavale & Forness, 1987).

Although a detailed review of learning disabilities subtypes is beyond the scope of this article, Table 3 depicts "consensus" subtypes arrived at by researchers in this area. This table is a brief summary of the review of the literature conducted by Weller and Strawser (1987) on social adaptation of children in different learning disabilities subtypes. The first column presents the five consensus subtypes that have been found. The second column depicts the cognitive deficits or processing patterns associated with each subtype pattern and, just below it, the social problems typically encountered by youngsters in that subtype as found in the studies reviewed. The third column gives the approximate percentages of the typical LD sample accounted for by the particular subtype.

Research on learning disability subtypes suggests that some types of children and adolescents with learning disabilities may be at risk for particular emotional or behavioral disorders (Forness, 1990). Indeed, Weller and Strawser asserted that the five subtypes are clearly identifiable by their differences in adaptive behavior and ability to cope with the environment.

Specifically, these authors provide a comprehensive review of the subtypes and the related adaptive capabilities related to coping mechanisms, adaptive language skills, compensatory behaviors, and behaviors that impact transition from school to community and employment. For instance, individuals in the nonlearning disabled subtype tend to be socially well adjusted and to cope adequately with their environment, whereas individuals in the verbal or nonverbal organization disorder subtypes have impaired adaptive capabilities. More specifically, individuals in the verbal organization disorder subtype tend to act out their wishes and frustrations by visual-spatial motor-based behaviors (e.g., hitting and punching) rather than communicating their wishes and frustrations by talking. Children with nonverbal organization disorders, on the other hand, tend to misperceive, or even withdraw from, social situations.

The study of the adaptive behavior of subtypes of individuals als with learning disabilities has allowed for a clearer understanding and appreciation of individual strengths and limitations in terms of social competence. However, it is possible that more specific research is needed in this area beyond the general notion of social competence. Such research might also focus on developmental psychopathology with reference to specific psychiatric disorders that undergird social skills deficits. Although no research has yet pursued this hypothesis, it seems possible that children with learning disabilities in subtype 2 would qualify for a diagnosis of ADHD, in subtype 3 for a diagnosis of conduct disorder, and in subtype 4 for a diagnosis of depression or dysthymia.

CONCLUSION

More investigation into the hypothesis that social skills deficits are due to the comorbidity of learning disabilities with specific psychiatric disorders would be informative since there seems to be considerable evidence of emotional or behavioral difficulties in the population of children and adolescents with learning disabilities. As noted, comorbidity of learning disabilities within samples of individuals with disorders such as ADHD and depressive or dysthymic disorder may range as high as 25% (American Psychiatric Association, 1994). This could well mean that differences in social skills ratings between LD and non-LD samples found in previous studies are largely due to extreme scores within LD samples of children with these psychiatric disorders. In addition to comorbidity prevalence rates, the maladaptive social skills patterns of children with specific subtypes of learning disabilities appear to mimic the symptom patterns of children with ADHD and depression or dysthymia, thus providing additional support for the hypothesis that social skills deficits may stem from the comorbidity of learning disabilities with other diagnoses.

There is apparently only one study that directly explores this hypothesis to date. Lopez et al. (in press) examined 60 children with LD in the primary grades on a social skills rating scale. Those with both LD and comorbid ADHD or other emotional or behavioral disorders (N = 42) were significantly lower in social skills, classroom social behavior, and academic competence than those children with only LD (N = 18). There were, however, no significant differences in IQ or achievement. The social skills and related ratings of the LD-only group, moreover, were at or above the normal range, thus tending to confirm the comorbidity hypothesis.

What are the educational placement and treatment implications of the psychiatric comorbidity hypothesis? When ADHD, depression or dysthymia, or another psychiatric disorder occurs concurrently with a learning disability, there appears to be a need for increased special education support. As seen in the study of children characterized by a combination of a learning disability or a related behavioral difficulty or depression (Forness, 1988), "trimorbidity," or the addition of a learning disability, seemed the surest guarantee of such services. It could well be that children ultimately found eligible for SED or LD categories represent this trimorbidity. The presence of children with learning disabilities in SED programs or children with serious emotional disturbance in LD programs needs to be more systematically investigated. Our traditional assumptions of homogeneity in such programs may not lead to effective intervention for children who are comorbid for both psychiatric disorders and learning disabilities.

In turn, the most effective form of treatment merits careful consideration. Treatment of social skills deficits in children or adolescents with learning disabilities has focused primarily on educational interventions, that is, direct instruction, instead of therapeutic interventions such as psychotherapy (Nelson, 1988). If ADHD and depression account for significant numbers of social skills difficulties in the LD population, the treatment is apt to be much more complex than social skills training. For instance, when a child with learning disabilities reports symptoms typical of those seen in the subtyping research for adaptive skills deficits, ADHD or depression should be assessed in the diagnostic process. Likewise, when interpreting test results and making recommendations, professionals should be cognizant of the possibility that the child may have ADHD or depression. Thus, children or adolescents with learning disabilities whose difficulties in social or behavioral adjustment may well be due to comorbidity with ADHD or depression could benefit from therapeutic, psychological, or even psychopharmacologic treatment (Forness & Kavale, 1991). Psychopharmacologic treatment may in turn produce very different effects on learning as opposed to behavior, and this may be complicated by the presence of several disorders (Forness, Swanson, Cantwell, Guthrie, & Sena, 1992).

Explorations of subtypes of children with learning disabilities and the resultant determination of different patterns of cognitive or psychologic dysfunction may help reduce children's difficulties to more understandable and manageable types of problems (Forness, 1990). It is unfortunate that previous studies in learning disabilities have largely ignored the potential for comorbidity between learning disabilities and specific psychiatric disorders. Likewise, a variety of medical diagnoses such as prenatal substance abuse, fetal alcohol effects, and fragile X syndrome may potentially have associated diagnoses in both behavioral disorders and learning disabilities (Forness & Kavale, 1994). The need for collaborative efforts between professionals in mental health and learning disabilities may be the most important implications of a psychiatric comorbidity hypothesis.

Footnotes: See website listed below.

Requests for reprints should be addressed to:

Steven R. Forness, UCLA Neuropsychiatric Hospital,

760 Westwood Plaza, Los Angeles, CA 90024.

http://www.ldonline.org/ld_indepth/social_skills/psychiatric_comorbidity.html

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