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PSYCHIATRY - THEORY, APPLICATIONS AND TREATMENTS
LEARNING DISABILITIES
ASSESSMENT, MANAGEMENT AND
CHALLENGES
RODNEY PARSONS
EDITOR
New York
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CONTENTS
Preface vii
Chapter 1 The Nosological Status of
Developmental Dyscalculia 1
Júlia Beatriz Lopes Silva, Ricardo Moura and
Vitor Geraldi Haase
Chapter 2 Metacognition and Learning Disabilities in
Higher Education 25
Lucia Rodríguez-Málaga, Rebeca Cerezo and
Celestino Rodríguez
Chapter 3 Hearing Loss and Intellectual Disabilities 61
Siobhán Brennan and Sarah Bent
Chapter 4 “I Will Make a Difference”; Using the 5As Model to
Improve Issues for Adults with Learning Disabilities
and Hearing Loss 91

Lynzee McShea
Chapter 5 Instructional Methods for Teaching Sub-Types of
Students with Reading Disabilities Chinese Words 135
Fuk-chuen Ho and Cici Sze-ching Lam
Chapter 6 Impact of Challenging Behaviour on Families and
Avenues for Support 153
Evan Yacoub, Haulie Dowd and Leigh McCann
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vi Contents
Chapter 7 Integrating Students with Disabilities in Academia:

A Rewarding Challenge 173

Elena Ponomareva, Nitza Davidovitch and
Yair Shapira
Chapter 8 How Do Academic Institutions Integrate Students
with High-Functioning Autism? (Report) 183
Elena Ponomareva, Nitza Davidovitch and
Yair Shapira
Nova Related Publications 197
Index 199
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PREFACE
This book contains assessments, management options and challenges

for individuals with learning disabilities. Chapter One reviews whether there
is enough clinical-epidemiological evidence to support the definition of
dyscalculia as a nosological category. Chapter Two examines current findings
and scientific evidence that is needed to better understand metacognitive
ability in higher education students with learning disorders. Chapter Three
discusses the importance of hearing loss identification and rehabilitation,
aimed at professionals across different disciplines and also as a starting point
for those new to the audiology profession. Chapter Four details a piece of
original qualitative research, designed to improve audiological issues for
adults with learning disabilities and hearing loss who are supported by paid
caregivers. Chapter Five focuses on the examination of the major deficits of
reading in English and Chinese writing systems; reviews instructional methods
to the sub-types of students with reading disabilities; and introduces recent
developments in teaching programs for students with reading disabilities.
Chapter Six discusses the impact of challenging behaviour on families and

provides avenues for support. Chapter Seven shows the way Ariel University
in Israel is dealing with the goal of giving students with learning disabilities an
opportunity of being part of society and the academic world. Chapter Eight
examines whether and to what extent academic institutions integrate students
with high-functioning autism.
Chapter 1 - The concept of “Specific Learning Disorder” refers to a group
of conditions in which there is a discrepancy between school achievement and
general cognitive skills. Those difficulties should not be better explained by
other primary causes, such as developmental, neurological, sensory or motor
disorders. Learning deficits are associated to marginalization of the children
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viii Rodney Parsons
and this may also lead to difficulties in social life in adulthood. Research
regarding the nosological status of learning disorders is very controversial,

especially after the recent change in the Diagnostic and Statistical Manual of
Mental Disorders (DSM-5) diagnostic criteria: the new approach broadened
the category, leading to a single, overall diagnosis of impairments that impact
school achievement, instead of limiting it to specific diagnosis of reading or
mathematics skills, for instance. Despite the studies about the cognitive and
neurobiological basis of dyscalculia being quite recent compared to research
on other learning disabilities, there is current evidence that dyscalculia would
constitute a specific learning disorder, such as neuropsychological double
dissociations to other disorders (i.e., dyslexia).The present chapter aims at
reviewing whether there are enough clinical-epidemiological evidences that
support the definition of dyscalculia as a nosological category.
Chapter 2 - Educational research has noted metacognition as a necessary
skill for the development of an independent, constructive and meaningful
learning, and determinant in academic success or failure of students. In the
same way, distance learning is an increasing option for universities and
research has shown the relationship between the self-study character of
these virtual learning platforms and the use of metacognitive strategies to
deal successfully with virtual training. The question is what is the role of
this construct and his implications when the authors deal with college
students with learning disabilities? To answer this question the authors have
systematically reviewed the literature in the last decade combining the
following descriptors at Web of Science and Google Scholar: metacognition,
metacognitive strategies, learning disabilities, higher education, and
postsecondary. The relevance of metacognitive strategies is clearly supported
by the current findings. However, there are contradictory results regarding
differences in metacognitive ability of college students when compared with

their peers with difficulties and the processes underlying. This chapter arises
further discussion about current findings and scientific evidence that is needed
to better understand metacognitive ability in higher education students with
learning disorders.
Chapter 3 - There is a high prevalence of hearing loss in individuals with
intellectual disabilities and it can affect communication, personal relationships
and mental health. Awareness of this issue is increasing, as is the authors’
ability to assess hearing and offer appropriate rehabilitation, however
significant developments in audiological care and management are still
required and further research needed. This chapter discusses the importance of
hearing loss identification and rehabilitation, aimed at professionals across
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Preface ix
different disciplines and also as a starting point for those new to the audiology
profession. Various points on the Audiological care pathway for people with
intellectual disabilities are presented including: identification of individuals
who require hearing loss investigation, methods of assessment of hearing loss,
and appropriate rehabilitation. This chapter includes the challenges faced by
PwID and hearing loss and by clinicians. The chapter will conclude with some
of the authors’ recommendations for improved Audiological care for PwID.
Chapter 4 - This chapter details a piece of original qualitative research,
designed to improve audiological issues for adults with learning disabilities
and hearing loss who are supported by paid caregivers. The research study
comprised of four action research cycles. The first cycle involved visiting and
interviewing paid caregivers in their workplace to explore their baseline
knowledge and experience of hearing loss and hearing aids. Findings indicated
that the majority of participants underestimated the prevalence of hearing loss
and had inaccurate knowledge regarding assessment and hearing aids.
Symbolic interactionism was used as a theoretical tool to account for their
perspectives.
The second cycle involved designing and piloting a training package for a
wider group of caregivers. The content and delivery of the training was
informed by suggestions from participants of cycle one and other key
stakeholders. Situated learning and experiential learning theory were the
theoretical basis for the training design. 44 individuals were trained across 6
homes and constant refinement of the training occurred throughout the pilot
phase. Early indications were positive; participants’ knowledge and
confidence increased post training and pledges were made to continue the
change process.
The third cycle was concerned with evaluation of the effectiveness of the
training. Follow up visits were made to each home and a reassessment of

knowledge and confidence suggested the improvements had largely persisted.
Within six months, 96% of all pledges made had been achieved and the
estimated prevalence of hearing loss in those supported by staff increased from
23 to 54%, with several new confirmed diagnoses of hearing loss. Focus group
discussions were held with staff to explore their experiences post training.
Many described “new chapters” in their working lives, suggesting they had
completed their own cycle of experiential learning. These discussions also
revealed barriers to Audiology within primary care which necessitated
investigation in a further cycle.
The fourth cycle involved visiting and interviewing primary care
practitioners in their workplace in order to explore their experiences, in a
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x Rodney Parsons
similar manner to cycle one. Findings from this group suggested a significant
underestimation of hearing loss in people with learning disabilities and

negative attitudes around the worth and benefit of referral.
This study has shown that training in audiological issues can evoke a
change in working practice, which had not been demonstrated in the literature
prior. Contact between caregivers and Audiology was also important and the
need to develop the role of Audiology within the community, transpired as
one of the key findings of this research. Theoretical development of the
findings has led to creation of a conceptual model (the 5As model), which
acknowledges the need for multidisciplinary engagement in assessment and
management of hearing loss in people with learning disabilities. Though the
model was created for hearing issues, it has broader application and relevance
across other health disciplines.
Chapter 5 - This paper consisted of three parts. The first part focused on
the examination of the major deficits of reading in English and Chinese
writing systems. Based on the dual-route model of reading, it was argued that
readers could use either phonological or/and orthographical processing to read.
The role of phonological and orthographic processing in both languages was
discussed. The deficits in using either one of the routes can cause various sub-
types of reading disabilities. Students with surface dyslexic pattern are
assumed to have impaired orthographic abilities, whereas those with
phonological dyslexic pattern are assumed to have difficulties in the
phonological processing. These two sub-types of reading disabilities can also
be found in Chinese writing system S. The second part dealt with the
corresponding instructional methods to the sub-types of students with reading
disabilities. Phonological analytic method and whole-word method are the
usual instructional methods to deal with the diverse needs of the students. The
phonological analytic instruction was more beneficial to students with surface

dyslexic pattern whereas the whole word method was more beneficial to
students with phonological dyslexic pattern when reading single characters.
Lastly, this paper introduced the recent development in teaching programs for
students with reading disabilities. Learning Chinese characters in word family
and story-telling is found to be effective for students with reading disabilities.
Chapter 6 - In this chapter, the authors discuss family carers of people
with Learning Disability and challenging behavior and the difficulties they
may encounter. The impact of challenging behaviour on carers is discussed.
Family training programmes are outlined and types of respite provision and
supports for the carers to avail of are discussed. The authors argue how the
case for increasing respite provision and family supports can be strengthened,
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Preface xi
and how services can be lobbied to ensure this happens. The authors discuss
why increasing supports for this population makes sense including financial
sense. The authors explore training opportunities for carers to ensure that
time spent with family members with Learning Disability and challenging
behaviour is of good quality. The authors conclude by emphasising the
importance of providing support and training to families in order for them to
continue in their caring roles.
Chapter 7 - The percentage of youth diagnosed with disabilities is
increasing steadily, becoming an issue that the society has to deal with in a lot
of attention. Granting academic education to these young people enables them
to become productive and self-supporting. University has opened its doors to
these students, allowing them to study any subject they desire and the authors
are ready to offer all the conditions that the students need.
The intellectual capabilities of most of these students are more than
sufficient for coping with the academic environment. The most difficult task is
to teach students to achieve success. For most of them, it is the first time they
are on their own and have to cope with basic issues as shopping, handling
money, or doing laundry. The University is ready to provide a social mentor
for each student that teaches trivial everyday activities, so that the graduate
will become independent. All of these and much more is an essential part of
this fascinating program that provides the authors’ graduates with the full
capability of becoming an independent productive member of the society.
In this article the authors show the way Ariel University is dealing with
the goal of giving those students an opportunity to be a part of the society and
the academic world.
Chapter 8 - The present study examines whether and to what extent
academic institutions integrate students with high-functioning autism. In the
past decade, it was found that academic institutions admit such students and
have also established student support systems to aid their successful
integration in academic studies, based on a belief in the principle of integrating
students from different backgrounds. This study follows several case studies
and presents findings of the situation in academic institutions. Findings
may have practical applications for the integration of students with high-
functioning autism, the development of intervention programs, and the
integration of these students in society; therefore the beliefs and attitudes of
those who play a role in these students’ integration are a key to this process.
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In: Learning Disabilities ISBN: 978-1-63485-840-3
Editor: Rodney Parsons © 2016 Nova Science Publishers, Inc.
Chapter 1
THE NOSOLOGICAL STATUS OF

DEVELOPMENTAL DYSCALCULIA
Júlia Beatriz Lopes Silva1, 2, Ricardo Moura2

and Vitor Geraldi Haase1,2,
1
Programa de Pós-graduação em Saúde da Criança e do Adolescente,
Universidade Federal de Minas Gerais, Belo Horizonte, Brazil
2
Developmental Neuropsychology Laboratory, Department of Psychology,
Universidade Federal de Minas Gerais, Belo Horizonte,Brazil
ABSTRACT
The concept of “Specific Learning Disorder” refers to a group of
conditions in which there is a discrepancy between school achievement

and general cognitive skills. Those difficulties should not be better
explained by other primary causes, such as developmental, neurological,
sensory or motor disorders. Learning deficits are associated to
marginalization of the children and this may also lead to difficulties in
social life in adulthood. Research regarding the nosological status of
learning disorders is very controversial, especially after the recent change
in the Diagnostic and Statistical Manual of Mental Disorders (DSM-5)
diagnostic criteria: the new approach broadened the category, leading to a
single, overall diagnosis of impairments that impact school achievement,
instead of limiting it to specific diagnosis of reading or mathematics
skills, for instance. Despite the studies about the cognitive and

Corresponding author: Júlia Beatriz Lopes Silva, juliablsilva@gmail.com.
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2 Júlia Beatriz Lopes Silva, Ricardo Moura and Vitor Geraldi Haase
neurobiological basis of dyscalculia being quite recent compared to

research on other learning disabilities, there is current evidence

that dyscalculia would constitute a specific learning disorder, such
as neuropsychological double dissociations to other disorders (i.e.,
dyslexia).The present chapter aims at reviewing whether there are enough
clinical-epidemiological evidences that support the definition of
dyscalculia as a nosological category.
Keywords: dyscalculia, nosology, diagnostic
THE NOSOLOGICAL STATUS OF DYSCALCULIA

Research on developmental dyscalculia is not new but still lags behind in
what has been investigated about dyslexia and attention-deficit/hyperactivity
disorder (Gersten, Clarke and Mazzocco, 2007). Searching in the PubMed on
June 14th, 2016 resulted in 29982 entries for “ADHD,” 8912 entries for
“dyslexia,” and but only 1430 for “mathematics learning disability.” Research
interest in DD is, however, growing, and evidence is accumulating in three
major directions: a) neuropsychological (McCloskey, Caramazza and Basili,
1985) and neurocognitive models (Dehaene, 1992; Dehaene and Cohen, 1995),
b) neuroimaging (Arsalidou and Taylor, 2011; Kaufmann et al., 2011), and c)
genetic-molecular research (Docherty et al., 2010).
A nosology aims at identifying clusters of symptoms that reliably co-occur
and that differ regarding their etiology, pathogenesis or response to treatment
(Pennington, 2009). Only a few studies have considered the nosological status
of DD. Regarding reliability and replicability of diagnostics, there are scarce
data. One main reason for that is the multiplicity of diagnostic criteria and
underlying neurocognitive mechanisms related to DD. Interestingly, regardless

of the fine-grained definition employed in the studies, DD seems to be a stable
condition across time (Mazzocco and Myers, 2003, Shalev et al., 2005).
Moreover, it is now possible to identify children at risk of later developing DD
when they are already in kindergarten (Geary et al., 2009, Mazzocco and
Myers, 2003, Mazzocco and Thompson, 2005). Data also suggests that DD is a
risk factor for emotional and behavioral disorders (Auerbach et al., 2008). Low
math achievement also adversely affects employment and wages in adult life
(Parsons and Bynner, 2005). Studies indicate that DD is an heterogeneous
condition regarding its etiology, mechanisms and comorbidities (Rubinstein
and Henik, 2009) and that only a small proportion of individuals may present
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The Nosological Status of Developmental Dyscalculia 3
“pure forms” of the disorder, related to deficits in basic numerical abilities

(Dirks et al., 2008, Landerl and Moll, 2010, Reigosa-Crespo et al., 2011).
The nosological status of learning disabilities has been mainly
characterized regarding their internal and external validity (Pennington, 2009).
This concept of internal validity is analogous to the internal validity
of psychological tests. In the cases of learning disabilities, evidences of
internal validity concern the diagnostic coverage, homogeneity and subtypes,
reliability of classification with different diagnostic tools, samples and
examiners and differential diagnosis. DD is a very heterogeneous disorder
(Rubinsten and Henik, 2009) which makes it difficult to support its internal
validity. Regarding reliability and replicability of diagnostics, there are scarce
data. One main reason for that is the multiplicity of diagnostic criteria and
underlying neurocognitive mechanisms related to DD.
The external validity essentially concerns the explanatory significance of
disorder. According to Pennington (2009) the possible criteria for discriminant
external validity are: prevalence, etiology, neurocognitive mechanisms,
prognosis, response to intervention and clinical relevance (Pennington, 2009).
In the following sections, we will discuss each of these topics.
DEFINITION AND DIAGNOSIS OF DYSCALCULIA

Developmental dyscalculia (DD) belongs to the group of “Specific
Learning Disorders.” Its definition is fundamentally based on behavior and
exclusion criteria, since biological markers for the clinical diagnosis have not
been established yet. It is characterized mainly by difficulties in numerical
processing and basic calculations, which impair school achievement, as well as
daily life activities which require number manipulations. Those difficulties

must not be better explained by developmental, neurological, sensory (vision
or hearing), or motor disorders and must significantly interfere with academic
achievement, occupational performance, or daily living activities.
The behavioral diagnosis is usually based on standardized arithmetics test,
such as the “School Achievement Test,” used in the Brazilian context. The
main problem with this sort of tests is that they are not based upon
neurocognitive models and, as a consequence, can be extremely unspecific.
They would usually include arithmetical problems taught and practised in
schools and, furthermore, children who are not dyscalculic, but struggle
with arithmetic for different reasons, may also present poor performance.
Butterworth and colleagues (2003) have developed a computerized
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Dyscalculia screener that aims at identifying dyscalculia, and to separate it

from the other causes of poor numeracy attainment by means of a timed-based

test. There is still no consensus regarding the best diagnostic tools that should
be used. Nevertheless, some diagnostic criteria are still mostly based on these
tests, such as a two-year discrepancy between arithmetic achievement and
school grade or 1.5/2 standard deviation below the expected mean for
the school grade. Another important diagnostic criteria, which was specially
emphasized in the changes on DSM 5, is the response to intervention
(Fletcher, Lyon, Fuchs and Barnes, 2007). The Criterion A refers to the key
characteristics of SLD: at least one of six symptoms of learning difficulties
that have persisted for at least 6 months despite the provision of extra help or
targeted instruction. This most recent version of the DSM also introduced a
big change regarding the exclusion of the IQ-Achievement discrepancy
criterion. This criterion has been the target of heavy criticism (Fletcher, et al.,
2007). Another important change in the DSM 5 was the exclusion from the
subtypes of learning disabilities, which were replaced by an overarching
category, with specifiers to describe the problems. This change may be useful
in the context of educational systems that allows special education for children
with disabilities, nevertheless, the diagnostic criteria has become less specific
and it may be harder to define the specific traits of them.
The response to intervention (RTI) criterion has also been tentatively
employed to increase both sensitivity and specificity of DD diagnostics
(Fletcher et al., 2007, Mazzocco, 2007). The rationale behind the RTI
procedure consists in early screening of children under risk of developing DD
followed by effective intervention. If the child fails to respond to proper
intervention, it can be diagnosed with DD, with a higher level of confidence.
However, the RTI criterion is both work- and time-consuming and therefore
difficult to implement. Moreover, there are currently no generally accepted

screening and intervention procedures. Finally, besides the presence of DD,
attitudes towards mathematics, such as math anxiety, motivation, and intensity
of training are also reasons why an intervention fails to bring positive results.
Terminology inconsistencies and lack of cognitive or neurobiological
markers represent hindrances to a more precise definition and diagnosis of
DD. The term DD is usual among neuropsychologists, while developmental
and educational psychologists use a broad spectrum of labels, ranging from
“low achievement” and “mathematical difficulties” to “mathematical learning
disorder or disability,” depending on the criteria.
Mazzocco (2007) reviewed the literature on definitions and diagnostic
criteria, and proposed that the 5th percentile should be the cutoff point to
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identify children and adolescents with DD or mathematical learning

disability (MLD), while the 25th percentile was recommended as a more liberal
criterion to identify children with mathematical difficulties (MD). Mazzocco's
recommendations are grounded both on statistical as well as cognitive
reasons. Research has shown different statistical criteria may sample
different populations. Participants selected on a stricter criterion have a
higher probability of having persistent and stable difficulties (Mazzocco and
Myers, 2003). Mazzocco and Myers (2003) also disclosed evidence that the
probability of an inherent disorder, in a neurobiologically based core disorder
of magnitude representation, is higher in the group with persistent difficulties.
Non-persistent difficulties identified by a more liberal criterion are more prone
to exogenous influences, such as quality of cultural and educational influences.
We advocate that a uniform terminology should be employed. Mazzocco's
(2007) proposal has the advantage of reconciling neuropsychological and
developmental/educational literatures. Moreover, the system proposed by
Mazzocco (2007) also has the advantage of distinguishing between children
with different degrees of impairment in numeric and arithmetic abilities.
PREVALENCE AND COMORBIDITIES

The prevalence of DD is estimated to be between 3 and 6% of the general
population (Butterworth, 2005; Fletcher et al., 2007). There has not been
consistent evidence so far regarding sex differences in prevalence rates
(Butterworth, 2005; Dowker, 2005).
Comorbidity is frequently observed in DD (Rubinsten and Henik, 2009),
in the sense that pure cases may correspond to less than 30% of the total
(Desoete, 2008, Dirks et al., 2008). DD has high comorbidity rates with
Developmental Dyslexia and Attentional Deficit Disorder (ADHD). It is also
important to note the high co-occurrence of oppositional behavioural disorders
and anxiety and low self-esteem problems (Auerbach, Gross-Tsur, Manor and
Shalev, 2008). The high comorbidity rate is a confounding factor which makes
it difficult to precisely estimate the prevalence, as well as to identify the
cognitive deficits, in each learning disability (LD) (Rubinsten and Henik,
2009). One can even question whether there is specificity at all regarding
selective deficits in each LD. The comorbidity rates between dyscalculia and
dyslexia are higher than what would be expected by chance, if both entities
were independently segregated. At the same time, the comorbidity is relatively
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specific, once the probability of having dyscalculia in a family with

dyscalculia is higher than having dyslexia. Besides that, questionnaires

answered by parents suggest that the transmission is specific to each disability
and that reading and math disabilities show a co-segregation pattern (Landerl
and Moll, 2010).
A solution to this puzzling situation is the concept of endophenotypes
(Bishop and Rutter, 2009), which corresponds to the intermediary steps of
environmental and self regulation, with multiple loci from the genome to the
phenotype. Investigations aim at characterizing and distinguishing the
endophenotypes associated to the different learning disabilities from the
neurobiological perspective, using structural and functional neuroimaging; as
well as from the cognitive perspective, by means of neuropsychological
research. The most obvious disadvantage would be the multiplication of
entities. Diagnostic labels should be created to address several subtypes of
dyscalculia, such as one possibly associated to language disorders (Jordan
et al., 2003), and other related to ADHD (Kaufmann and Nuerk, 2008).
Different cognitive mechanisms could contribute to distinct subtypes of DD.
Phonological processing deficits could be implicated in language-related
forms, while working memory or executive dysfunctions could explain
dyscalculia associated to ADHD. Nevertheless, the whole picture must be a bit
more complicated: an example is that Kaufmann and Nuerk (2008) disclosed
basic number processing deficits in children with ADHD.
The problem of comorbidity is, in great measure, derived from
the way neuropsychology has traditionally conceived structural-functional
correlations. Relying on double dissociations between impaired and preserved
psychological processes, neuropsychology has emphasized functional
specialization (Stevens, 2009). Newer approaches provided, for example, by
genetic-molecular and neuroimaging research, are arousing interest on

integrative mechanisms. Behavioral and molecular-genetic mechanisms
disclosed that comorbidities originate from both shared and nonshared
variance between different mechanisms (Docherty et al., 2010, Landerl and
Moll, 2010) and this lead to the new concept of generalist genes (Kovas
and Plomin, 2006). According to this perspective, functional specialization
emerges from the interaction of general and specific genetic mechanisms with
the environment. The challenge is to delimitate each endophenotype that
constitutes the complex phenotypic manifestations of each and every patient.
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ETIOLOGY
The etiology of DD is probably multifactorial, being associated

to alterations in multiple genes that interact with the environment. Genetic
research indicates the high rates of familial recurrence (Landerl and Moll,
2010; Shalev et al., 2001) and high heritability coefficients in twin studies
(Alarcón, DeFries, Light and Pennington, 1997). In 2010, the first complete
genomic screenings for DD were published (Docherty et al., 2010). Several
polymorphisms from unique nucleotides were associated to mathematical
performance. Nevertheless, the effect sizes were small and additive, and the
variance in performance was explained both by domain-general and domain-
specific factors.
It is also interesting to note that DD is part of the phenotype of different
genetic syndromes, such as Turner Syndrome, X-fragile Syndrome in girls
(Bruandet, Molko, Cohen and Dehaene, 2004; Murphy and Mazzocco, 2008),
Velocardiofacial Syndrome (De Smedt et al., 2009), and Williams Syndrome
(Krajcsi, Lukacs, Igacs, Racsmany and Pleh, 2009). This association to those
syndromes suggests that, besides the multifactorial etiology, DD is related to
the disruption of specific loci. The occurrence of DD in the Foetal Alcohol
Syndrome (Kopera-Frye, Dehaene and Streissguth, 1996) can be considered an
evidence in favor of multiple genetic effects associated to environmental
influences. Regarding cultural and socio-environmental influences on the
arithmetic performance, there is an impact of socio economic status. This
influence is more evident in more complex aspects of numerical cognition,
such as the solution of orally formulated arithmetic problems (Fuchs and
Fuchs, 2002). The socio-environmental influences can also be associated to
differences in general cognitive skills that are relevant to arithmetic
performance, such as intelligence (Strømme and Magnus, 2000) and working

memory (Noble, McCandliss and Farah, 2007).
Clarifying which are the underlying neurobiological mechanisms of DD is
a major step towards establishing its nosological validity and justifying clinical
and educational use of the concept.
NEUROBIOLOGICAL AND COGNITIVE MECHANISMS

The diversity of tasks involved in mathematics challenges the study of the
cognitive and neuroanatomical bases of the mathematical thinking. In order to
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be able to perform mental calculations, learn the multiplication table, convert

between Arabic and verbal numerals, counting and representing numerical

quantities, one needs to engage a wide range of cognitive mechanisms, such as
working-memory, long-term memory, magnitude representation and language,
which are instantiated in different brain circuits (Zamarian, Ischebeck and
Delazer, 2009).
Currently, the most widespread neurocognitive account for dyscalculia
assumes that the math difficulties derive from a ANS impairment. Concurrent
theories focus on more domain general abilities, such as verbal/visuo-spatial
working memory (Geary, 1993, 2004), phonological processing (Hecht et al.,
2001; Simmons and Singleton, 2008), visuospatial processing (Rourke, 1993),
attention and inhibitory control (Gilmore et al., 2013). Next, evidences for
each of these cognitive mechanisms will be reviewed in more detail.
a) Approximate Number System Acuity
The approximate number system (ANS) is a built-in cognitive process that

allows the spontaneous representation of numerical magnitudes (Izard and
Dehaene, 2008; Piazza, 2010). Its functioning can be described according to
the Weber and Fechner Laws. The Weber’s law states that the minimal
numerical change that can be discriminated increases in direct proportion to
the magnitude of the numerosities (that is, it depends on the ratio between
the magnitudes). Later, Fechner demonstrated that Weber’s law could be
accounted for by postulating that external numerosities are internally scaled
into a logarithmic internal representation of sensation.
Some authors argue that ANS development is a precondition for
the acquisition of symbolic representations of numbers, thus allowing the

development of exact arithmetic (Gallistel and Gelman, 1992; Dehaene and
Changeux, 1993; Piazza, 2010). The accuracy of ANS has been associated
with mathematics achievement in kindergarten (Libertus, Feigenson and
Halberda, 2011) as well as in elementary school (Halberda, Mazzoco and
Feigenson, 2008; Inglis, Attridge, Bachelor and Gilmore, 2011). Furthermore,
activities based on ANS training have shown to be efficient in improving math
performance (further discussed later in this chapter).
The ANS can be thought as the domain-specific mechanism that underlies
mathematics learning. Impairments in the ANS would lead to difficulties in
assigning meaning to numerical symbols and, consequently, to problems with
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arithmetics (Dehaene, 2009; Piazza et al., 2010), and therefore are described as
the core deficit in dyscalculia.

Piazza et al., (2010) were the first to find that children with mathematical
learning disabilities presented poorer ANS acuity as compared to same-
age peers. Specifically, they observed that the acuity in discriminating the
numerosity of sets of dots exhibited by 10 years-old dyscalculics was similar
to that observed in 5 years-old typically developed peers. This result was
corroborated by other researchers. Mazzocco, Feigenson and Halberda (2011)
added evidence showing that the ANS deficit observed in dyscalculic children
was larger than that observed in children with low mathematics achievement,
and it could not be accounted by domain-general abilities, such as short-term
memory, visual perception and word-reading skills.
Even though the ANS is important for mathematics, it does not seem to
play a crucial role on every numerical task, for example, converting
between different number notations (number transcoding). Cognitive models
(Barrouillet et al., 2004; Camos, 2008) claim that changing from one
numerical notation to the other is an asemantic process, in other words, does
not require access to the numerical magnitude, especially in the case of more
familiar and large numbers.
b) Working Memory
Working memory (WM) is involved in different abilities, among them,

the mathematical cognition (Geary, 1993; Rotzer et al., 2009; Fuchs et al.
2010). Geary (1993, 2006) proposed that the storage capacity related to the
phonological loop, as well as inhibitory mechanisms, are associated with the
acquisition and consolidation of arithmetic facts. In a longitudinal study, it was

verified that the phonological loop is related, more specifically, to basic
operations on which children use retrieval as the strategy for resolution,
instead of counting, for example (Geary, Hoard, and Nugent, 2012).
Working memory capacity has been strongly associated to number
transcoding, especially in writing Arabic numerals under dictation. It was
observed that children with higher span in phonological working memory
presented superior performance compared to those with lower span.
Furthermore, performance in number transcoding was also correlated with the
syntactic complexity of the items to be transcoded (Camos, 2008, Moura et al.,
2013). A study of 7 year-old German children suggested that visuospatial
working memory predicts the performance in transcoding tasks (Zuber, Pixner,
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Nuerk and Moeller, 2009). Fayol, Barrouilet and Renaud (1996) demonstrated
that the number of syllables of the number dictated could account for 33% of
the variance on a number writing task and they argue that this result could be
associated to the limited capacity of working memory. The role of WM in
transcoding tasks can be thus systematized in the following steps: encoding the
number to be transcoded; monitoring the application of transcoding rules and
the production of the numeral (Lochy and Censabella, 2005).
Passolunghi and Cornoldi (2008) demonstrated that one of the
best predictors of mathematical performance was the span of Corsi Blocks,
both in the group of typically developing children as well as in the
group of children with mathematics difficulties. In a recent study, we found
that, in children with and without math difficulties, even without group
differences in working memory, there is an overloading in WM while they
are solving arithmetic word problems that can be compensated by the
use of fingers (Costa et al., 2011).
c) Phonological Processing
Phonological processing is traditionally associated to reading and writing

acquisition. According to Wagner and Torgesen (1987), at least three
phonological skills are involved in word reading: a) phonological awareness,
which means the ability to perceive and manipulate phonemes that constitute
words; b) phonological working memory, involved in temporary retaining of
sound-based representations; and c) lexical access, which is related to the
retrieval of a written word from its lexical referent through the recoding into a
sound-based representational system. These skills play a pivotal role in the
development of reading and increasing interest has also been directed to the
possibility that it may be a factor constraining the development of both reading
and mathematics.
An important evidence that supports this association between reading
and mathematics is the difficulties in mathematics presented by children
with dyslexia, who have deficits in their phonological processing skills
(Griffiths and Snowling, 2001; Vellutino, Fletcher, Snowling, and Scanlon,
2004). Approximately 40% of dyslexic children also have difficulties in
arithmetics (Lewis, Hitch and Walker, 1994) and the prevalence of
reading and mathematical difficulties is similar, around 4 to 7% (Landerl,
Fussenegger, Moll, and Willburger, 2009). It is assumed that the phonological
representations of dyslexic children are weak, which leads to an impairment in
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cognitive processes that utilize phonological codes. The finding that dyslexic
children are impaired on tasks that require the manipulation, retrieval and
retention of phonological codes is consistent with a core deficit in representing
phonological information (Snowling, 2000; Vellutino et al., 2004). There are
alternative theories that aim to explain the difficulties presented by dyslexic
children, such as the temporal processing hypothesis (Tallal, Miller, Jenkins,
and Merzenich, 1997) and the cerebellum impairment hypothesis (Fawcett and
Nicolson, 2001; Nicolson and Fawcett, 2001), but, in general, the phonological
deficits are still the most hegemonic and accepted point of view.
“Mathematical cognition” is a more general term that encompasses verbal
(e.g., counting, arithmetic fact retrieval) and nonverbal domains (e.g.,
subtizing, nonsymbolic magnitude comparison) (Simmons and Singleton,
2008; De Smedt et al., 2010). Recent studies have focused on the influence of
phonological processing in mathematical achievement (Landerl, Bevan, and
Butterworth, 2004; Simmons and Singleton, 2008; Landerl, Fussenegger,
Moll, and Willburger, 2009) and it is hypothesized that phonological
processing may be more strongly connected to the aspects of mathematics that
involve verbal codes as well as Arabic number representations.
Simmons, Singleton and Horne (2008) reported that phonological
awareness (by means of a rhyming task) measured at 5 years of age
predicted arithmetic and reading attainment one year after. Similarly, Leather
and Henry (1994) also reported that 31% of the variance in 7-year-old
children’s arithmetic performance could be explained by a composite score of
phonological awareness tasks.
Hecht, Torgesen, Wagner and Rashotte (2001) investigated the influence
of these subcomponents in a longitudinal study with children from 7 to 11
years old. They concluded that phonological processing skills measured on
2nd grade strongly predicted mathematical outcomes in 5th grade even when
controlling for the autoregressor effect of prior math ability. Moreover,
phonemic awareness was the only subcomponent that influenced mathematical
outcome growth on 3rd and 4th grade. According to the authors, the influence
of phonological short-term memory and rate of access may be limited to the
second- to the third- grade time interval.
Some authors claim that the influence of phonological processing in
arithmetic could be due to shared demands with working memory, since these
effects can be eliminated when partialling out the influence of working
memory (Swanson and Sachse-Lee, 2001; Swanson, 2004). It is important to
notice that the relationship between working memory and phonological
processing could vary according to the instruments used.
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Regarding number transcoding, specifically Arabic number writing, the

input is verbal, hence one must be able to differentiate between sounds of

language to correctly comprehend the verbal number that will be transcoded
into the Arabic form. Despite this possible impact of phonological skills in
the transcoding performance, no study has simultaneously and systematically
investigated the relationship between these two variables. Transcoding
requires the engagement of domain-general cognitive skills, such as working
memory and cognitive models claim that access to the numerical magnitude
is unnecessary in transcoding large numbers (Barrouillet et al., 2004;
Camos, 2008). As it also demands the use of verbal/phonological codes, the
probability that they are dysfunctional in children with developmental dyslexia
or comorbid developmental dyslexia plus dyscalculia is possibly high.
d) Visuospatial Processing
As explained before, the internal representations of numbers is considered

to be spatially oriented, from left to right, with increasing overlap between
adjacent numbers (logarithmic compression). This representation is referred as
mental number line. One important source of evidence for this spatial
orientation of numerical representations is the spatial-numerical association of
response codes, or SNARC effect. As first shown by Dehaene, Bossini and
Giraux (1993), when performing parity judgment tasks, subjects tend to
respond faster with the left hand for smaller numbers, and faster with the right
hand for larger numbers. It was hypothesized that visuospatial deficits would
lead to an abnormal development of the spatial coding of the mental
number line. Bachot, Gevers, Fias and Roeyers (2005) addressed this issue
comparing the SNARC effect exhibited by children with combined numerical

and visuospatial deficits and typically developed children. The authors
observed the SNARC effect in the comparison group, but not in children with
visuospatial and mathematical deficits, thus concluding that these children
have a representational deficit of numerical information.
Another method for assessing this is the number line task, in which
participants have to assign numbers to its position in a segment line
representing a numerical interval. It has been consistently shown that children
with mathematics difficulties have a less precise performance in this task,
when compared to control peers (Booth and Siegler, 2008; van den Bos et al.,
2015).
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Another source of evidence for an association between visuospatial

abilities and arithmetic in children comes from the neuropsychological

research on Velocardiofacial Syndrome (VCFS). Simon et al., (2005)
discovered deficits in the orientation of attention. Comparatively to controls,
no differences were observed in a subitizing task, while VCFS participants
were impaired in counting sets of stimuli, a task requiring visual attention.
These data were interpreted in terms of a lower spatial resolution, a kind of
“visuospatial granularity,” which may hamper finer time, visuospatial and
magnitude processing (Simon, 2008).
Besides representational deficits, abnormal visuospatial abilities may lead
to operational difficulties in solving arithmetics. In the quest for clinical
classification of children with non-verbal learning disability, Rourke and
collaborators (Rourke, Ahmad, Collins, Hayman-Abello, Hayman-Abello, and
Warriner, 2002; Drummond, Ahmad, and Rourke, 2005) proposed that
visuospatial deficits would lead to difficulties in mechanical arithmetics, that
is, in applying arithmetical procedures such as aligning multi digit numbers in
order to calculate a subtraction, and using carrying and borrowing strategies.
PROGNOSIS
Some of the reasons why dyscalculia deserves the status of a valid
nosological entity are the persistence of the difficulties and the high potential
to hamper academic and professional life, as well as psychosocial adjustment
(Parsons and Bynner, 1997, 2005). In a long-term perspective, considering
periods from 5 to 10 years, the probability that a diagnosis of dyscalculia will
persist is above 70% (Shalev, Manor, and Gross-Tsur, 2005).
INTERVENTION
The relations between core numerical abilities and mathematics
achievement, as well as its involvement in DD occurrence, have been well
established over the last years (Butterworth, Varma and Laurillard, 2011;
Landerl, Bevan and Butterworth, 2004; Landerl, Fussenegger, Moll and
Willburger, 2009; Halberda, Mazzocco and Feigenson, 2008; Mazzocco,
Feigenson and Halberda, 2011; Mussolin, Mejias and Noel, 2010; Piazza et al.,
2010). It has been argued that an appropriate training of basic abilities would
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induce an improvement on basic and also on more complex mathematical

tasks. Main inspiration comes from dyslexia research, which showed that
specific training on the core process of phonological awareness improves
general performance on more high-level abilities (for an example, see:
Torgesen, et al., 2001).
One of the first contributions regarding number sense training effects was
given by Dehaene and his collaborators with the software Number Race, a
computer game developed to work as a training tool for children with low
arithmetic performance (Wilson, Dehaene, et al., 2006; Wilson, Revkin,
Cohen, Cohen, and Dehaene, 2006). In a playful environment, children
compete against the computer on a variety of early arithmetic aspects, like
comparing numbers and set of dots (choose the larger), counting, linking
symbols to concrete quantities, and simple calculation. Their first results
indicated a significant improvement in performance on the more basic
numerical cognition tasks, like number estimation and comparison, and also on
subtraction, after the training period (Wilson et al., 2006). In the same line,
Wang, Odic, Halberda and Feigenson (in press) showed that increase in ANS
acuity is accompanied by improvement in symbolic mathematics scores.
Other results come from studies conducted by Siegler and coworkers
(Ramani and Siegler, 2008; Siegler and Ramani, 2008, 2009), who described
how other training software works on preschoolers. Their program is based on
the strengthening of number-space relationship representations by means of
classical numerical board games. According to their results, numerical board
games practice is capable to improve performance on numerical magnitude
measures and, therefore, reduce individual differences between preschoolers
on those abilities. Children with lower performance on numerical knowledge
tasks exhibited, after the training epoch, performance levels similar to that of
children with previous high performance on a variety of number tasks,

especially magnitude estimation, digit naming, addition and magnitude
comparison. The best results were found when comparing children from
discrepant socioeconomic neighborhoods. In this sense, core number
knowledge training is capable to fill the gap existing on the numeric-related
stimulation provided by their home and social environments, strengthening
the link between symbolic and nonsymbolic representations of number.
Additionally, one of their most outstanding discoveries was the training effect
on subsequent arithmetic learning. Children who first had practiced on the
board game exhibited better results on subsequent arithmetic problems
learning, indicating that early number magnitude training has a cumulative
effect on later mathematical comprehension (Siegler and Ramani, 2009).
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Kucian and coworkers (2011) evaluated the efficacy of a computer-based

training program on DD rehabilitation by means of neuropsychological testing

and functional magnetic resonance imaging (fMRI). Computer training was
very similar to a regular video-game (with challenging goals and a motivating
story) where the player should associate numerical stimuli (Arabic numbers,
dot sets or simple calculation) to the correct location on a number line. After
training, both magnitude representations and neurofunctional changes were
investigated. There was a significant improve in performance after retest for
number line estimates and arithmetic achievement for both groups, but it was
more relevant for the DD one. Regarding neurofunctional effects of the
training program, results point to a reduction in the activity levels of
magnitude processing related areas (bilateral intraparietal regions), suggesting
an automation of the cognitive processes related to numerical competence. A
similar approach was later reported by Käser et al., (2013). After a period of
6 to 12 weeks of daily training, children showed significant benefits in
mathematical skills, as well as on self-efficacy perception.
Another approach, proposed by Gilmore, McCarthy and Spelke (2007),
aimed at developing word problem solving abilities. These authors worked
with preschool children, prior to any formal arithmetic instruction. They
presented word arithmetic problems to children on a computer program, which
required simple addition or subtraction procedures to manipulate sets of
visually displayed objects, such as candies. Children were encouraged to
estimate the answer without counting. Experimental conditions manipulated
the magnitude distances between the sets to be operated on. Quantitative
differences between operand were initially large, being progressively reduced.
With training, children improved their ability to provide increasingly precise
answers and developed an intuitive grasp of the problem-solving strategy. The
study by Gilmore and coworkers suggests that nonsymbolic approximate

estimation operations may play a role in the development of arithmetic
problem solving if the magnitudes involved in the problems are large enough
to be easily discriminated.
Together, these studies constitute the first main progress regarding the
remediation of core numerical abilities. Unfortunately, results still should be
interpreted carefully due to reduced sample sizes and limited methodological
designs. Nonetheless, evidence points to the efficacy and reliability of
activities that deal with basic mathematical concepts like magnitude
estimation, counting and number reciting, and also regular board games, on
both school and home contexts. It is clear that core numerical abilities
stimulation, on the very first school years, is capable to remediate and improve
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current numerical performance, and also has a long term effect on later
mathematical learning.
CONCLUSION
Even though the increase in research focusing on numerical processing is
quite recent, it already has an important impact on the clinical and educational
field, especially concerning diagnostic criteria and, consequently, intervention.
In the last decades, with the development of cognitive-neuropsychological and
neurocognitive models, the assessment of mathematical skills has become
more common. This has lead to a debate on the behavioural and neurogenetic
aspects of DD and many research methods have been used to investigate these
questions. In summary, in spite of the fact the research on DD is on the
beginning stage, there is enough evidence that supports it can be defined as a
valid nosological entity, with specific diagnostic, prevalence and etiological
characteristics.
The most imperative research questions concern the definition of the
associated neurocognitive mechanisms, as well as the development of efficient
diagnostic and intervention strategies. The elucidation of the underlying
mechanisms of mathematical processing will contribute to the comprehension
of DD. It will also support the validity of the syndrome from the
clinical epidemiological point of view, as well as the development of
consensual diagnostic criteria for its detection in clinical and educational
contexts. Although fragmentary, current knowledge allows risking some
recommendations. From the clinical-epidemiological point of view, uniformly
consistent diagnostic criteria are desirable and detailed characterization
of the several endophenotypes, their contribution to the disabilities and neural

underpinnings will improve diagnosis and management. The multiplexed
influences on math achievement and their disorders, suggest educators should
be aware of the several possible causes, mechanisms and manifestations of low
math achievement. Accordingly, interventions should focus and integrate
different levels of mechanisms and approaches.
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Chapter 2
METACOGNITION AND LEARNING

DISABILITIES IN HIGHER EDUCATION
Lucia Rodríguez-Málaga*, Rebeca Cerezo and

Celestino Rodríguez
Department of Psychology, University of Oviedo, Spain
ABSTRACT
Educational research has noted metacognition as a necessary skill for
the development of an independent, constructive and meaningful learning
(Bustingorry and Mora, 2008; Conley, 2008; Pintrich and Zusho, 2002;
Pintrich, 2004), and determinant in academic success or failure of
students (Coutinho, 2007; Young and Fry, 2008). In the same way,
distance learning is an increasing option for universities (Tirado-Morueta,

Pérez-Rodríguez and Aguaded-Gómez, 2011) and research has shown
the relationship between the self-study character of these virtual
learning platforms (Esteban Albert and Zapata Ros, 2008) and the use
of metacognitive strategies to deal successfully with virtual training
(Azevedo, Behnagh, Duffy, Harley, and Trevors, 2012; Azevedo,
Cromley, Moos, Greene and Winters, 2011). The question is what is the
role of this construct and his implications when we deal with college
students with learning disabilities? To answer this question we have
systematically reviewed the literature in the last decade combining the
*
Corresponding author: Rebeca Cerezo. University of Oviedo. Department of Psychology. Plaza
Feijoo s/n, 33003, Oviedo, Spain. Telephone. +34-985109543; Fax: +34-985104144. Email:
cerezorebeca@uniovi.es.
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26 Lucia Rodríguez-Málaga, Rebeca Cerezo and Celestino Rodríguez
following descriptors at Web of Science and Google Scholar:

metacognition, metacognitive strategies, learning disabilities, higher

education, and postsecondary. The relevance of metacognitive strategies
is clearly supported by the current findings. However, there are
contradictory results regarding differences in metacognitive ability of
college students when compared with their peers with difficulties and
the processes underlying. This chapter arises further discussion about
current findings and scientific evidence that is needed to better
understand metacognitive ability in higher education students with
learning disorders.
Keywords: metacognition, learning disabilities, higher education
“Of all the possible knowledge, the wisest and most useful is self-
knowledge.”
William Shakespeare
INTRODUCTION
The human being is developing his abilities, acquiring new knowledges,
skills, habits, ideals, etc. throughout all his lifetime, and is, in overall, subject
of learning. Moreover, such learning enables to successfully adapt to an
“information society, of the multiple, uncertain knowledge and progressive
learning” (Pozo and Mateos, 2009, p. 54). It is beyond doubt that, among
the learning subject and the demanding society, the university plays an
exceptional role, since it can and must educate the subject, student and future
professional as an effective apprentice, able to autonomously and permanently
adapt to this reality on continuous renovation, that is, “learn to learn” (García
Martín, 2012; Núñez, Solano, González-pienda, and Rosário, 2006). In other

words, the education of the XXI century must guide their students to the
developing of their thinking abilities that ensure them to become active
subjects and autonomous of their own learning, to constantly improve and
optimize the resources needed when carrying out any task, as well as to get
along in a variety of environments (Monereo and Pozo, 2014). In this context,
researchers and professionals alike have attempted to search and delve on what
are those skills or abilities that steer to optimum and major learnings, pointing
thus the metacognition and metacognitive strategies as required construct and
starting point, in the way (sense) that they allow to know and think about
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Metacognition and Learning Disabilities in Higher Education 27
oneself and how one learns when becoming a self-regulated apprentice

(Rosario, et al., 2014; Pintrich, 2004; Zimmerman, 2002).

In the following lines and, after contextualizing the reader, we are
addressing metacognition and the learning disabilities concepts. We are also
describing some of the research carried out in university environments related
to this topics.
CONCEPTUAL DELIMITATION: METACOGNITION AND

SELF-REGULATED LEARNING
Metacognition
Etymologically, the word metacognition is compounded by the greek

prefix “meta”- beyond- and the latin word “cognition” – “cognoscere”,
namely, it stands for what is beyond cognition, to refer to the human ability
that allows to “take a glance to oneself thinking or cognition”. To Flavel,
(1979), one of the pioneers on this field, the metacognitive activity during the
learning process, is and implies, to trigger two aspects or dimensions:
metacognitive knowledge and metacognitive strategies.
The metacognitive knowledge is represented by three areas of cognition:
self-knowledge and everyone else, namely, intra-individual and extra-
individual knowledges; knowledge on the task, related to the particularities or
properties of the task; and the very determinant knowledge on the cognitive
strategies referred to “the ensemble of strategies that the student can apply to
learn, codify, understand and record the information, to the service of some
given learning outcomes” (Gonzales and Tourón, 1992, p. 390).
Regarding to strategies, one of the mostly accepted classifications until

now (Valle, Barca, González and Núñez, 1999) is the one provided by
Weinstein and Mayer (1983) which makes a difference between repetition,
organization and elaboration strategies. The first (repetition), for instance
when taking notes or repeating something loudly) have the goal of information
registering and working memory, they barely demand cognitive effort and are
associated to a shallow learning style. The organizational strategies, such as
making conceptual maps, as its own name suggests, allow detecting and
establishing inner coherence among the relevant aspects of the contents that
are to be learned. Finally, the elaboration strategies, e.g., the use of metaphors
or analogies, lead to a greater comprehension of the content, in the sense that
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they ease the codification and connexion between the previous knowledges
and the new ones, as well as its record for later use (Gonzalez and Tourón,
1992; Monereo, 1990). The learning on the strategy is not only declarative
(know that strategies exist) but also how must they be employed (procedural
knowledge) and under what conditions (conditional knowledge) (Bustingorry
and Mora, 2008; Pintrich, 2000). That is, what strategies are the best suited or
suitable in relation to the task and posed objectives (Valle, Cabanach,
González, and Suárez, 1998).
In order to improve the affinity between the aforementioned concepts, we
will illustrate the following example: Let us suppose that some student takes
an exam in two weeks. He knows that he must study during the afternoons
because at night tends to the tiredness (intra-knowledge), in difference to his
mate, who focuses better during night (inter-knowledge). If he is conscious
whether his personal notes taken during the lectures are incomplete and
will not enough to pass the exam (task knowledge), he may opt to search
bibliography and to make sketches and summaries, in order to acquire a
greater understanding of the subject (knowledge of the strategy).
Therefore, the first building block of the metacognition is the
metacognitive knowledge. But besides, there would be a second block, which
is given by the metacognitive strategies. In the words of Baker and Brown
(1984):
The second cluster of activities studied under the heading

metacognition consists of the self- regulatory mechanisms used by active
learner during and ongoing attempt to solve problems. These indexes of
metacognition include checking the outcome of any attempt to solve the
problem, planning one’s next move, monitoring the effectiveness of any
attempted action, and testing, revising and evaluation one's strategies for
learning. (p. 354)
Planning (setting objectives, strategic plan) monitoring, revising

(checking, reviewing and tracking the activity evolution) and evaluation
(rating the process as function of the goals and plan proposed) are
metacognitive strategies that, starting from metacognitive knowldedge, each
strategic student would employ to self-regulate his own thinking in the
learning process (level of knowledge that is acquiring, reconsideration of the
cognitive strategy adopted, etc.) In definitive, and following at Weinstein and
Mayer (1983, p. 4) “they are strategies of checking and controlling of the
comprehension”.
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Parallel to this process, and, dynamically generates, new sensations or

feelings which have a fundamental rol, for they allow the student to activate,
review or establish new objectives or strategies (Efklides, 2008, 2011; Flavell,
1979). Altogether is what has been referred to “metacognitive experience”.
This can be seen in four ways and in different moments (Pintrich, 2000, 2004):
at the beginning of the activity in the shape of an ease of learning judgments
(EOL), namely, judgements around the previous knowledge to the task
(efficiency in the past and previous analogous experiences); during the
learning, in the shape of judgments of learning (JOL) when for example, the
subject feels that he has not understood what he just read or, otherwise,
when he feels satisfied with the outcome; or in the shape of feeling of
knowledge (FOK) which, as its own name suggests, alludes to the sensation of
having knowledge about something, but being unable to remember it, a
phenomenon commonly referred as the “tip of the tongue”. Finally, the
Confidence Judgments or capacity, after performing some activity, to predict
the effectiveness.
Each one of the blocks that constitute the metacognitive activity is
represented in Figure 1.
Therefore, and to summarize up, we can affirm that the learning action,
that is, to grasp, integrate and apply all knowledges in an effective way,
contemplates a level jump (Efklides, 2008; Suengas y González-Marqués,
1993), making difference between cognition and metacognition and, in
consequence, between cognitive and metacognitive strategies. As affirm
Flavel (1979) “Cognitive strategies are invoked to make cognitive progress,
metacognitive strategies to monitor it”. (p. 909). To Gargallo (2009), we can
regard two levels: higher level or metacognitive, and lower level or cognitive.
Both will be coordinated and constantly feedbacked in the sense that the
cognitive strategies will follow the direction and orientation given by the
metacognition, i.e., the object of metacognition will the review and control on
the cognitive activity. In words of Alvares and Klimenko (2009):
To the metacognitive handling of the self-learning it is necessary to

develop a self about what to do. This allows the subject to learn, plan,
administrate, and regulate his self-learning and the problem solving
processes, through the choice, employment, modification and rating of
the suitable cognitive strategies. (p. 19).
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METACOGNITIV
METACOGNITIV
E STRATEGIES
E KNOWLEDGE
Planning
Person
Monitorig
Task
Revising
Strategy
Evaluation
METACOGNITIVE
EXPERIENCES
EOL JOL FOK
Confidence Judgments
Figure 1. Metacognition components.
Self-Regulated Learning
Metacognition and self-regulation, are two naturally interrelated

components which it has often been generated in a lack of agreement to
delimit both terms (Rosario, et al., 2014; Zulma Lanz, 2006). With the
contribution of Brown (1987) the concept of metacognition is extended by
introducing the regulatory component, and some authors have been using the
terms metacognition and self-regulation synonymously (Dinsmore, Alexander
and Loughlin, 2008). Nowadays, the most accepted approach differences
between metacognition and self-regulation (Zulma Lanz, 2006). In words of
Zimrneman (1995):
Self-regulation involves more than metacognitive knowledge and

skill, it involves an underlying sense of self-efficacy and personal agency
and the motivational and behavioral processes to put these self beliefs
into effect. Views of self-regulated learning that do not include this core
self-referential system have difficulty explaining human failures to self-
regulate, especially when such efforts are known metacognitively to be
helpful. (p. 217).
It is thus assumed that metacognition is a part of a more complex or global

construct (Pintrich, 2000, 2004; Zimmerman, 2002) known as self-regulated
learning, which is defined as (Pintrich, 2000):
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An active, constructive process whereby learners set goals for

their learning and then attempt to monitor, regulate, and control their
cognition, motivation, and behavior, guided and constrained by their
goals and the contextual features in the environment. These self-regu-
latory activities can mediate the relationships between individuals and the
context, and their overall achievement. (p. 253).
Now we will show the self-regulated learning process Pintrich approach,

one of the most representative, alongside with Zimmerman’s (2002) and
Winne’s (1998, 2003) that will approach the reader to the understanding of
each of their components and, hence, the role of metacognition during the
whole process.
Table 1. Phases and Areas for Self-Regulated Learning
Areas for regulation

Phases Cognition Motivation/Affect Behaviur Context
Phase 1 Target goal Goal orientation Time and effort Perception
Forethought setting adoption planning s of task
planning, Prior content Efficacy judgments Planning for Perception
and knowledge Perception of taks Self observations s of
activation activation difficulty of behavior context
Metacognitive Taks value activation Efficacy
knowledge Interest activation
activation
Phase 2 Metacognitive Awareness and Awareness and Monitorin
Monitoring awareness and monitoring of monitoring of g changing
monitoring of motivation and affect effort, time use, task and
cognition need for help context
Self-observation conditions
of behavior
Phase 3 Selection and Selection and Increase/decrease Change or

Control adaptation of adaptation of effort renegotiate
cognitive strategies for Persist, give up task
strategies for managing, motivation, Help-seeking Change or
learning, and affect behavior leave
thinking context
Phase 4 Cognitive Affective reactions Choice behavior Evaluation
Reaction and judgments Atributtions of taks
reflection Attributions Evaluation
of context
Note: Retrieved from “A Conceptual Framework for Assessing Motivation and Self-
Regulated Learning in College Students” by P. R. Pintrich, 2000, Educational
Psychology Review, 16 (4), p. 390. Copyright 2004 by Springer Science +
Business Media, Inc. Reprinted with permission.
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Hence, the self-regulated apprentice would be initiated in the activity as

planning and design the objectives to achieve. The perception of the task
would activate the set of the self metacognitive knowledges (about the general
working) and about the activity in particular (cognition area) as well as the
previous experiences, the first judgements on the task (metacognitive
experience) along the expectations and utility assessments (motivation area).
Also will take place the first estimations on the time or effort needed
(behavioral area) and the assessment on the environment organization and the
study place, in order to obtain the previous objectives (context area).
Straightaway and immersed in the learning, the metacognitive consciousness,
perception of the motivational mood, along the self-observation of the
behavior and the context (suitable management of time, need of assistance)
will be crucial to pick and/or modify the cognitive and motivational strategies,
as well as to initiate changes in the attitude (increase or decrease of the effort,
change or abandon of the context, etc.). Among all the results of this process
(success or fail), the apprentice will generate an assessment or causal
attribution (Valle, Rodríguez, Cabanach, Núñez, and González-Pienda, 2007),
and future behavior (election or not of the same set of strategies).
Therefore, according to Nuñez (2009) “to learn something new it is
needed to dispose the capacities, knowledges, strategies and skills to -can- and
have the enough mood, intention and motivation to -want- for achieving and
conquering the intended goals” (p. 41). In words of Zimrneman (1989) “we
will speak of a self-regulated apprentice in the way that he is compromised in
a metacognitive way, motivationally and in behavior to his own learning
process” (p. 329).
Metacognition and Higher Education
In the last few years, the study of the self-regulated learning and in
particular metacognition, has attained to become a key theme and of the
greatest importance for educators (Azevedo and Aleven, 2013; Garcí Martín,
2012; Montalvo and Torres, 2004; Núñez, Solano, González-Pienda and
Rosario, 2006; Rosario et al., 2014). In this sense, the results from the research
have pointed out as the use of metacognitive strategies as an essential factor
for the quality of the apprentices on pair of differential and explicative of the
students success or fail (Lamas Rojas, 2008; Zimmerman, 2002). For instance,
Pérez, Castellanos, Díaz, González-Pienda and Núñez (2013) analyzed in a
sample of university students the connections among the adoption of a deep
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approach of learning (not reduced to a memory or mechanic practice, but

towards to the integration, comprehension and connexion of the knowledge)

and the use of metacognitive strategies. They found that the adoption of a deep
approach of learning was strongly related to the metacognitive strategies. In
the words of the authors:
The students that employed predominantly a deep approach the also

occupied the thoroughest in metacognitive behavior, showing a greater
evaluation and consciousness of their own study processes and the
obtained results, pointing their attention towards the comprehension of
what they studied, assuming in greater way their own responsibility and
showing higher motivation for learning. (p. 144)
In the same Isaacson and Fujita (2006) examined in a sample of 84

bachelor students the relationship between metacognitive knowledge and
academic performance. They questioned themselves whether the most
successful bachelor students were those who had a greatest metacognitive
knowledge on the tasks that demanded superior thinking skills, and if this
could set their technique strategies as function of the most important
requirements for the task's achievement. The authors also found that the
students with the best performance were those who owned a higher level of
metacognitive knowledge, to more precise, realistic and with greater ability for
the choice and adaptation of techniques depending on the task's requirements:
As students are required to take on academic tasks of increasing

difficulty it is critical that they have the metacognitive skills to assess
their mastery of the material on a variety of levels. This metacognitive
self-assessment is essential to the application of self regulated learning.
(p. 53).
The study of metacognition not only has been linked to the performance,
but also with affective/emotive aspects. In this sense, some studies have
established mutual relationships and influences between metacognition, mood
and motivation, with important effects on learning (Efklides 2011; Palladino,
Poli, Masi and Marcheschi, 2010). The correlation between self-efficacy and
metacognition has also been object of research. Thus for example, in the study
of Coutinho (2008), it was found that the students who employed effective
metacognitive strategies also had a strong believe on their own work capacities
to carry out a given task (self-efficacy).
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At the same time, the addition of hypermedia Computer Based Learning

Environments (CBLEs) as processing support for the teaching-learning (T-L)

is a fact whose study and assess has acquired greater weight in the last few
years (Tirado-Morueta, Pérez-Rodríguez and Aguaded-Gómez, 2011).
Accordingly, educative investigation has pointed out the self-taught behavior
of the e-learning platforms (Esteban Albert and Zapata Ros, 2008) as an
element that needs metacognitive capacity to successfully handle the
hypermedia learning (Azevedo, Behnagh, Duffy, Harley, and Trevors, 2012;
Azevedo, Bouchet y Khosravifar, 2014; Azevedo, Cromley, Moos, Greene and
Winters, 2011; Gutiérrez, Palacios and Torrego Segovia, 2010). According to
Azevedo, Cromley, Winters, Moos, and Greene (2005):
Hypermedia environments requires a learner how to learn it, how

much to learn, how much time to spend on it, how to access other
instructional materials, whether he or she understands the material, when
to abandon and modify plans and strategies, and when to increase effort.
(p. 382).
Learning Disabilities (LD)
In contrast to the previous scenario, namely, the study of the self-regulated

learning and metacognition, which has an important theoretical corpus, the
research of the learning disabilities in adults and, more precisely, in graduate
students, is sparse and insufficient.
While existing research seems to support the sustainability on the
learning disabilities (Mcnulty, 2003; Reiff, Gerber and Ginsberg, 2014;
Swanson and Ju Hsieh, 2009), we still do not have a clean definition and
profile that accounts for the particularities in adulthood (Gregg, 2012). As

Ortiz González (2004) explains, we were forced to extrapolate what we know
(the term, characteristics, etc.) from child research and adolescents (Gerber,
2001). Nevertheless, as Gerber affirms (1998):
“What is problematic in a grade-school student can be very different

from what is manifested in an adolescent with a learning disability.
Similarly, learning disabilities in adulthood present some different
themes, challenges, and issues. Therefore, it is important to acknowledge
that the experience of being learning disabled varies as an individual
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progresses through the various levels of development childhood,

adolescence, and adulthood. (p10)
In other words, we need to adopt a vital cycle approach which accounts

for the age, stage of developing status in order to frame, understand and attend
to an adult population (in our case, university) which suffers from learning
disability (Ortiz González; 2004; Gerber, 1992).
Regardless, there are two definitions from the United States which, up to
now, seem to be the most acknowledged by different researchers, professionals
and field institutions of learning disabilities. One of those is given by the
National Joint Committee on Learning Disabilities:
A heterogeneous group of disorders manifested by significant

disabilities in the acquisition and use of listening, speaking, reading,
writing, reasoning, or mathematical skills. These disorders are intrinsic
to the individual, presumed to be due to central nervous system
dysfunction, and may occur across the life span. Problems in self-
regulatory behaviors, social perception, and social interaction may exist
with learning disabilities but do not, by themselves, constitute a learning
disability. Although learning disabilities may occur concomitantly with
other disabilities (e.g., sensory impairment, mental retardation, serious
emotional disturbance), or with extrinsic influences (such as cultural
differences, insufficient or inappropriate instruction), they are not the
result of those conditions or influences (NJCLD, 1994, p. 65)
In the same line, the Individuals with Disabilities Education Act (IDEA)
define them as:
A disorder in one or more of the basic psychological processes

involved in understanding or in using language, spoken or written, which
disorder may manifest itself in the imperfect ability to listen, think, speak,
read, write, spell, or do mathematical calculations. Such term includes
such conditions as perceptual disabilities, brain injury, minimal brain
dysfunction, dyslexia, and developmental aphasia. Such term does not
include a learning problem that is primarily the result of visual, hearing,
or motor disabilities, of mental retardation, of emotional disturbance, or
of environmental, cultural, or economic disadvantage (IDEA, 2004, Sec.
602 (30))
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Both definitions are part of what it is known as “restrictive conception of

learning disabilities”, whose acknowledgment as diagnostic category have

enabled to design and develop actions oriented towards the specific needs in
this collective. In contrast, in Spain, among others, learning disabilities have
not yet been constituted as a diagnostic entity by itself, but submitted inside
the Special Educative Needs (SEN), using both terms as equivalents in a wider
sense (Jiménez González and Hernández Valle, 1999; Jiménez, Guzmán,
Rodríguez and Ceferino, 2009). From this approach, learning disabilities are
considered a temporary problem (against the chronic problems, such as
sensory or physical) in the way that it would not be possible to include adult
subjects that exhibit this problematic (Ortiz González, 2004).
In this present work, we have taken a restrictive and differential approach,
that is, as a set of diverse problems inside the Special Educative Needs.
Besides, we will use the terminology in the same way than other authors, such
as Romero Pérez and Lavigne Cerván (2004), who understand that as part of
the learning disabilities one has, on the one hand, the specific learning
disabilities (dyslexia, dysgraphia, dyscalculia) and, on the other hand, the
attention deficit/hyperactivity disorder (ADHD). Both concur on the effects to
the performance. The SLD more specifically, whilst the ADHD more diffusely
and generically (Casas, Herrero and Ferrer, 2015).
Now we will make a brief explanation of the common elements that the
different approaches share and, at the same time, constitute the aforementioned
definitions. We will briefly explain also the kinds of learning disabilities
together with the features of the ADHD, highlighting the most distinctive ones
“heterogeneous group of disorders (…) are intrinsic to the

individual, presumed to be due to central nervous system dysfunction and
may occur across the life span”
Most of the authors agree on assuming that exists a starting neurological

dysfunction. Dysfunction that limits or hinders the correct psychological
processes that allows the learning of the basic competences such as reading,
writing and mathematics. This entails a lower performance not explained by a
lack on intellectual capacity (Taymans, 2012). From here one draws the three
most common kinds of disabilities: Dyslexia which, up to date, is one of the
most acknowledges and referenced sub-kinds in literature. Dysgraphia, with a
moderate study, and regard (Orza, Lazcano and Álvarez, 2002) alongside
dyscalculia.
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Regarding to Dyslexia or disabilities on the reading process, they all

are characterized by the presence of problems at consciousness level and

phonological processing. Such lack seems to be the most accepted and
supported empirically, even at neuro-image level (López-Escribano, 2007).
Regarding the Dygraphia, the problems would suggest a lexic problem,
focused to writing, and syntactic construction, for instance in the right use of
grammatic writing, as well as in the inner motor process, bad handwriting and
slow writing (Crouch y Jakubecy, 2007; Orza, Lazcano y Álvarez, 2002).
Lastly, the Dyscalculia which, generically, it would be defined as the
presence of problems in calculus, numeration and resolution of mathematical
computations, problems in the writing and reading of ciphers, in the mechanics
of easy operations, in the comprehension of the formulations, in the use of a
working memory to recall and represent numerical facts (Castro-Cañizares,
Estévez-Pérez and Reigosa-Crespo, 2009; Geary, 2004).
With respect to the diagnostic and following the criteria, the Diagnostic
and statistical manual of mental disorders-text revision- 5th edition ([DSM-V]
American Psychiatric Association [APA], 2013) establishes that in the first
place, the aforementioned disorders are extended, at least, throughout 6
months, despite the interventions oriented to alleviate such shortcomings. Such
aptitudes should be fundamentally and in quantitative level below to what it is
expected for the chronological subject's age and will interfere in the academic,
working and daily performances, though they will not be explained due to the
presence of further disorders (intellectual disabilities, visual, auditory, mental
or neurological disorders, psico-social problems, in a lack of academic
instructions or inappropriate educative guidelines)
Moreover, there is no certainty on the statement that all subjects who
present the same profile are equivalent. Diversity or heterogeneity with
respect to the distinctive features that compound the rank of specific learning
disability, can be understood in both ways (Ortiz González, 2004): inter-
individual, namely, the difficulties are manifested in different ways among the
individuals that share such condition, and inter-individual: differences in the
same subject, either when comparing diverse areas, or given by function of the
developing stage.
According to the definition from the el National Joint Committee
on Learning Disabilities, another existing problem in people with learning
disabilities is a shortfall in the self-regulated behavior: “problems in self-
regulatory behaviors, social perception, and social interaction may exist with
learning disabilities but do not, by themselves, constitute a learning disability”
(NJCLD, 1994, p. 45)
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The scientific research in metacognition and its relations to the learning

disabilities starts already in the 80’s, when some authors, as Torgensen (1977)
or Swanson (1990) posed the possibility of explaining the problems of this
collective as a result of the ineffective developing of the metacognitive
strategies. Ever since, educational and cognitive psychologies were concerned
on delving the study and its relation between metacognition and learning
disabilities. Consequently with the traditional literature, some studies carried
out in adolescents (Pintrich 1994) seem to confirm the differences in the
metacognition capacities between subjects with and without SLD. Currently, it
has been defined these subjects as inactive learners (Romero and Cerván,
2005), when adopting a cognitive behavior, lacking of motivation and for
suitable learning strategies, adapted to the content (Bravo Valdivieso 1994). It
seems that such differences would not be only at a general level (Hen y
Goroshit, 2012; Palladino, Poli, Masi and Marcheschi, 2010) but specific,
namely, related to the learning disabilities. Thus for instance Garrett,
Mazzocco and Baker (2006) examined the metacognitive skills, or more
precisely, the metacognitive experience (through the confidence judgements)
in a sample of children with (n = 17) and without (n = 179) specific learning
disabilities in mathematics during troubleshooting. The authors concluded that
children with disabilities where less accurate on their judgements and
assessments about the (in)correct answers.
ADHD has come to form part of the diagnostic category labeled
as disorder by attention deficit and disturbing behavior (DSM-IV-TR, APA
2001) together with the DEA under the condition “neurological disorder of
developing” in the DSM-V(APA, 2013), alluding thus to an intrinsic neuro-
psychological origin, far from a contextual approach (Casas, Herrero and
Ferrer 2015). Following the DSM-V we quickly comment some of the most
representative characteristics: According to the DSM-V, this disorder is

chiefly characterized by the existence of shortfalls at attention level, (for
instance losing things, forgetting daily activities, easiness to loose focus) are
neglected or worsened, the work is not accomplished accurately as well as
problems related to hyperactivity.
The symptoms of inattention or hyperactivity-impulsiveness must be
present in two or more contexts and at least for six months. They would not
been produced only during the evolution of schizophrenia or other psychotic
disorder and cannot be explained better by means of other mental disorder.
The diagnostic criteria of the DSM-V are employed regardless for
children, adolescents and adults. It is thus acknowledged by its durability
throughout the lifespan. In words of Ramos-Quiroga (2006) “The prevalence
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of ADHD in the general adult population is estimated to be around 4%. Over

50% of the children with the disorder will continue to have it as adults” (p.
600). The authors also point out a light difference in youngsters, which is a
lesser hyperactivity and impulsiveness, but with the same attention disorders.
Moreover, it seems to exist some agreement in authors when referring to the
performance dysfunction as the chief deficit and reflex, not only of the control
of the inhibitory problems in behavior (Shuck and Crinella, 2005; Wasserstein
and Lynn, 2001), but also the metacognitive problems associated to such
disorder (Romero-Ayuso, Maestú, González-Marqués, Romo-Barrientos and
Andrade, 2006). Thus for instance, Barkley (2010) stresses the importance of
the comprehension of the metacognitive function in the ADHD as possible
differential barrier to other disorders that share similar features. Cognitive
deficiencies in ADHD, and as equal as the SLD, seem to be manifested in the
development of strategies (deficit in the troubleshooting) and incapacity to
plan and handle self-behavior, namely, metacognitive deficiencies (Barceló,
2005).
Metacognition, Learning Disabilities and Higher Education
Although apparently it does not exist a pointing element of the learning

disabilities, which on the other hand turns them into an “invisible handicap”
(Longo, 1988), what is real is that a great number of students with learning
disabilities are taking graduate studies (Taymans, 2012). In words of
Lombardi, Murray and Gerdes (2012): one of 10 undergraduate students do
have some sort of learning disability. Literature has stressed not only the
problems that they have in the development of metacognitive strategies, but
also in the lack of interventions to help them with a visible scientific basis
(Gerber, 2012; Floyd, 2012; Gregg, 2012). Currently, as Ortiz Gonzalez
(2004) suggests, most of the interventions are focused on primary school and
on the handling of the most basic learnings (reading, writing, mathematics).
It is not surprising therefore that the skills to learn and acquire new
knowledges, as well as to successfully and consciously use them were not
fully deployed when arriving at higher school, being a cause of a low
performance (Pérez, Castellanos, Díaz, González-Pienda and Núñez, 2013),
complete fewer academic credits (Bergey, Deacon and Parrila, 2015; Murray
Goldstein, Nourse and Edgar 2000) and even a dropout rate up to two to
three times higher (Taymans, 2012). In fact, it can be founded some
agreement among the authors that strengthens the lack of skills and academic
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preparation of this collective (Gregg, 2007; Mull, Sitlington and Alper,

2001). An extremely interesting study in this aspect is the one made by

Klassen, Krawchuk, Shane and Sukaina (2008). They assessed in a 208
undergraduate students sample with (n = 101) and without (n=107) SLD,
the relation between procrastination, self-efficacy and self-regulation. The
authors found that the subjects with learning disabilities displayed
significantly higher levels of procrastination, alongside the lowest levels of
metacognitive self-regulation and academic self-efficacy. Within this frame
that demands to act with greater self-regulation and autonomy (Cerezo
Menéndez, 2010), we ask ourselves: what is the role of metacognition
and his implications when we deal with college students with learning
disabilities?
Method
To answer to this question, it has been carried out a systematic review

which, as rightly remarks (Grant and Booth, 2009) in the aim to gather and
analyze the available evidences in what concerns the study of metacognition in
undergraduate student with learning disabilities, concretely the ones in
the Web of Science and Google Scholar. The terms employed to locate the
works were a combination of the keywords: metacognition, metacognitive
strategies, learning disabilities, higher education, and postsecondary. The
search was restricted to the years 2005-2015, both in English and Spanish.
Results
In overall it has been selected 8 articles. Only those whose main subject
was the study of metacognition in undergraduate students with learning
disabilities within the last 10 years. To record and organize it has been made
a table with the following fields: source (authors, publishing year), sort of
study (research methodology), sample (number of participants) and aspects
addressed in the research (Table 2).
In order to shed some light on this topic we will now detail each one of the
studies that have been found and their main achievements and conclusions.
Trainin and Swanson (2005) attempted to observe if students with learning
disabilities compensate their deficits of phonological processing by leaning on
metacognition? and, if the use of metacognitive strategies or metacognitive
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control a key to the success of these students. For that purpose, the authors
compared the cognitive and metacognitive behavior in a 40 undergraduate

students sample with and without learning disabilities. They analyzed on the
one hand, the phonological process (they took measures of the word reading,
working memory, general, semantic and speed processing) and on the other
hand, metacognitive capacity. The results supported a generalized deficit on
the processes related to reading on students with learning disabilities. On
the contrary, the metacognitive measurements did not reveal significant
differences. The authors concluded that the experimental group did not
compensate their disabilities through the employment of higher levels of
metacognition that their peers. To answer to the second question about the use
of metacognitive strategies a key point to the student’s success, authors, from a
combination of marks obtained in the MSLQ questionnaire (used to measure
the (meta)cognitive strategies) divided both groups into two conditions: low-
high employment of the metacognitive strategies (See Table 3).
They found that the SLD subjects (condition: high strategy) attained, in
average, marks as high as their peers NSLD (condition: high strategy) and
even higher than the NSLD (condition: low strategy) no matter therefore, the
limitation of the learning disability. Besides, the SLD (condition: low strategy)
have, on average, lower marks than any other group (SLD condition: high
strategy and NSLD, both conditions). The researchers concluded that the SLD
benefited much more from the employment of the metacognitive strategies and
therefore, they were crucial for the success of those students.
Kirby, Silvestri, Allingham, Parrila and La Fave (2008) focused on
identifying the strategies and learning process taken by 102 individuals
coming from four Canadian universities. They divided the subjects into two
parties: control group (n = 33) with a dyslexia previous diagnostic and an
experimental group (n = 66) made out of “normolectores” subjects. They
compared both the reading capacity as in the learning strategies through the
questionnaire LASSI, as well as the learning approach (measured with the
questionnaire SPQ-R). The results confirmed the disabilities in the reading
process in subjects with dyslexia. It was also found a strategic profile different
in both parties: In a difference with respect to the control party, the dyslexic
subjects shown a weaker result on the choice of the main idea and the
strategies followed when taking exams. On the contrary, the use of assistances
for study, time management and adoption of a deeply-rooted learning
approach appeared to be the strongest points of this party. To the authors, the
metacognitive behavior of this class could move on in two directions: positive
and negative. Negative: The learning disabilities in the reading process would
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provoke a great demand of the cognitive resources preventing the development

of the metacognitive capacity and the strategies related to the setting,

assessment and management (choice of the main idea and strategies to take
exams) Positive: the disabilities in the learning process would provoke an
increase of the metacognitve activity, acquiring thereby a compensatory rol.
This would be translated onto the strategic search of assistances to the study,
time management or, through the adoption of a delver learning approach.
The authors concluded that both directions represented adaptations to the
learning behavior in order to face the shortcomings related to the learning
disabilities.
Table 2. Selected papers according to search criteria
Source Kind of study Sample Aspects studied

Bergey, B. W., Descriptive-correlative N = 847 Reading metacognitive
Deacon, S. H. and strategies.
Parrila, R. K (2015) Cognitive strategies
Performance
Chevalier, T. M., Descriptive-correlative N = 372 Reading metacognitive
Parrila, R., Krista, C. strategies.
and Deacon, S. H. Metacogntive strategies
(2015). Cognitive strategies
Performance
Furnes, B. and Descriptive-correlative N = 44 Metacognition (knowledge,
Norman, E. (2015). strategies and experience)
Compensation
Hall, C. W. and Descriptive N = 55 Metacognition
Webster, R. E. Motivational factors (self-
(2008) effectiveness, Control Locus of
resiliency, need of achievement
Effectiveness
Kirby, J. R., Silvestri, Descriptive-correlative N = 102 Learning strategies (cognitive
R., Allingham, B. H., and metacognitive)
Parrila, R. and La Compensation

Fave, C. B. (2008).
Reaser, A., Prevatt, Descriptive N = 150 Learning strategies (cognitive
F., Petscher. and and metacognitive)
Proctor,B (2007) Effectiveness
Tops, W., Callens, Descriptive N = 200 Metacognitive experience
M., Desoete, A., (confidence judgements)
Stevens, M. and
Brysbaert, M. (2014).
Trainin, G. and Descriptive N = 40 Metacognition
Swanson, H. L. Compensation
(2005).
Source: self elaboration
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Table 3. Results from Trainin and Swanson (2005)

Experimental group Control group

(With Specific learning disabilities (Without Specific learning difficulties =
= SLD) NSLD)
High strategy Low strategy High strategy Low strategy
condition condition (n = 9) condition (n = 9) condition (n = 11)
(n = 11)
Furnes and Norman (2015) starting from the set of ideas exposed by Kirby
(2009) and in the aim obtain a greater information about the relation between
metacognition and dyslexia decided, by means of a reading test, to rate the
three components of metacognition: knowledge, strategies and experience.
They used a sample consisting of 44 undergraduate students from ten dutch
universities that were divided into two groups: experimental, subjects
previously diagnosed during primary and secondary school (n = 22) and
control group (n = 22). For the evaluation of the knowledge and metacognitive
strategies the employed two questionnaires of self-report. The metacognitive
experience was assessed by the capacity of the subjects to predict their
performance through the learning judgements. They used two textbooks, for
each of them, they took two measures: one after 5 minutes (at the middle of
the text) and other one at 10 minutes (at the ending) where they were asked
through a Likert scake (four choices: from less probable to very probable) to
indicate the number of questions they thought they would be able to answer
(referred to the part of the text they have just read). The authors found that
both groups had the same level of performance on each of the metacognition
components and, perhaps, such performance analogous was being some reflex
of compensation.
Chevalier, Parrila, Krista and Deacon (2015) examined in a sample of 372
undergraduate students (with precedent reading disabilities n = 77; without

precedents of reading disabilities n = 295) the existence, on the first place, of
differences on metacognitive reading, metacognitive study and behavioral
study and learning strategy. Metacognitive Reading was measured by MRSQ;
Metacognitive study, Behavioral study and learning strategy by means of
LASSI.
On second place, the relationship between those behaviors and academic
performance. The academic performance was measured through the Grade
Point Average (GPA), since they tracked the academic course of the
participants. Both groups completed at the beginning of the course the
questionnaires ARHQ-R, LASSI y MRSQ. The authors assumed that the
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students with HDR (history of reading difficulties) would have a lower marks
average, would inform a lower use of the metacognitive reading, learning, and
study strategies but more behavioral study and learning strategies than students
without HRD. Consequently to what was expected, the results revealed lower
marks in the experimental group. Furthermore, the variance analysis revealed
that the HDR group had lower levels of specific metacognitive strategies (of
reading) and learning strategies (cognitive and metacognitive). The results of
the multiple regression shown that, for the students with HRD the use of
strategies (metacognitive and cognitive) was associated to higher levels of
academic performance. The authors concluded that the use of metacognitive
strategies was a nice predictor for the academic success for the students with
HRD and also pointed out that, the measurements of self-inform employed
could be useful to identify the groups of students potentially at risk of low
academic performance.
In the same line, Bergey, Deacon and Parrila (2015) attempted to
determine the presence of differences among the students with and without
precedents of reading disabilities (HRD = 244; NHRD = 603 respectively) in
the use of metacognitive strategies of reading, cognitive and metacognitive
strategies (measured by the MRSO -A and LASSI). They also examined the
relation between the adoption of strategies and academic performance. In
comparison to their peers, HRD obtained lower marks on the two measures of
strategic behavior: their overall average marks was also lower. Nevertheless
and, in difference with the previous study, no significant correlations between
the use of strategies and academic performance (GPA) were found. The
authors concluded that the HRD subjects could be employing unique strategies
or not regarded in teh LASSI and MRSO-A which might be the explanation
for such performance.
Tops, Callens, Desoete, Stevens and Brysbaert (2014) tested the

hypothesis of the double load. According to it, people with a certain learning
disability would suffer twice as a result of, on the one hand, the incapacity to
carry out the associated tasks with the specific deficits of their difficulty, and
on the other hand, the insufficient development of the metacognitive capacity.
More precisely, the authors assumed that, the subjects with learning
disabilities would have problems to cast confident judgments or, which is the
same, to assess when they have performed some task correctly or incorrectly.
To confront the hypothesis, they ask 100 students with dyslexia and 100
normoreaders in order to rate their metacognitive experience in a word-
orthography and in a task of correction of proofs. To the assessment of the
metacognitive experience (confidence judgments) they employed a Likert sort
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scale of three alternatives (certainly, correct, rather certain correct, uncertain).

They found that the students with dyslexia were as good as their peers
when casting confidence judgments. They only had more cases where their
orthography was wrong. The authors confirmed that persons with dyslexia
would not suffer twice (double load) as the result of the insufficient
developing of the metacognitive competences.
Reaser, Prevatt, Petscher and Proctor (2007) compared the learning
strategies in students with ADHD, SLD (13 percent dyslexia, 25 percent
dyscalculia, 32 percent dysgraphy and 30 percent of the subjects with a
mixture of more than one difficulty) and without any kind of difficulty. They
tried to know further, if such strategies could predict the subjects academic
success. 150 students participated, divided into two groups: experimental
(SLD and ADHD, n = 100) and control (n = 50). They used the LASSI scale
as measure. The results drawn from the regression analysis revealed
differences with the control group and among the subjects that conformed the
experimental group. With respect to the first ones, the two areas where the
ADHD and SLD made with less effectiveness than in the control group where:
Information Processing and Self-Testing. A low mark on these scales
would mean a problem when, not only managing the information in order
to successfully process it, but also in the capacity of reviewing the
comprehension and development
With respect to the second ones, ADHD informed about the lowest marks
than SLD in: Time Management, Concentration, Selecting Main Ideas, and
Test Strategies. Seemed thus to present greater difficulties to employ effective
strategies in time management, lower attendance capacity, isolate the relevant
information from the whole content as well as to set the study to the kind of
exam. On the contrary, the SLD group obtained higher scores than the ADHD
(or even than the control group) in the scale of assistances to the study.
However, only the motivation was a strong predictor from GPA.
The authors emphasized on the one hand, the relevancy of the
deterioration of the metacognitive and self-regulated behaviors (lowest marks
in all the measures related to the strategic learning) and on the other hand, the
differences found among TDAH and SLD when providing for suitable actions
to the referred disability or disorder, as well as to the affected areas.
Hall and Webster (2008), unlike their previous colleagues, attempted to
see in a 55 students sample, possible differences around: metacognitive
capacity, affective factors (resiliency, self-efficacy, locus of control, and need
for achievement) and GPA. The experimental group was formed by 27
students, the control group was conformed by 28 volunteer students (n=28)
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without any kind of previous diagnostic of learning disability. They provided

the following questionnaires: WAIS-III (to scale the effects of the

intelligence); the EPQ (to assess metacognition); The Hall Resiliency Scale
(HRS); The College Self-Efficacy Inventory (CSEI); Locus of Control Scale
(LOC) y Need for Achievement Scale (NACH).
The results from the analysis revealed the absence of significant statistical
differences among the two groups in the WAIS-III, EPQ, LOC and NACH
scores. Neither in the averages marks. Nonetheless, the experimental group
obtained significant higher marks in the sub-scale of initiative and worse
marks in self-efficiency. The authors concluded that even the experimental
group has attained a level according with their peers in what intellectual skills
(metacognitive capacity) and performance are concerned. This seem not to
have effect on a self-efficiency improvement, neither in the confidence of their
capacities, who seemed to harbor doubts and inferiority feelings with respect
to their mates.
Discussion from Existing Work
Before drawing any kind of conclusion or recommendation, it is necessary

to briefly comment on the limitations of the previously exposed researches.
On the first place, although the drawn conclusions by the authors are
backed up by the data evidence they obtained and were linked to the goal of
the study, not all the authors took into account or detailed the methodological
limitations of their research, which, might have interfered in the obtained
results and, thence, in the subsequent conclusions and implications.
On the second place, in Method section, in some cases, the participants
characteristics where not specified: sort of difficulty, presence or absence of

previous diagnostic, age, gender, neither the obtaining procedure, nor the
selection of the sample. In relation to this last fact, those studies where the
sample had a previous diagnostic, the size was quite limited. Not only that, but
also, most of the subjects presented a diagnostic of dyslexia. Taking both
factors into account and their influence in the sample’s representatively, the
possibility of generalizing the results to a population with learning disabilities
would be affected. In what concerns the procedure or research's performance
(moment in which the data was taken, given instructions to the participants,
etc.) not all the studies had included it.
Regarding the assessment instruments, the employment of the self-report
questionnaires was a constant. Most part of the researchers used the LASSI,
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MRSQ or EPQ scales. Until now, in the field of research, these questionnaires
seem to be the most extended, mainly by their administration easiness and

interpolation (Montalvo and Torres, 2004). However, their suitability and
validity in the assessment of the cognitive and metacognitive strategies has
been highly controverted (Winne, 2002). Among the limitations that this
technique poses, we can find for example the possible difference in the answer
of the questionnaire and real practice of the students (Baker and Cerro, 2000;
Winne and Noel, 2003; Winne, 2002). Other problem is the difficulty to reach
or fully understand the required information in the questionnaire, that is, what
and whose are the metacognitive strategies employed during the study or
learning task. In this sense, Nuñez, Solano, Gonzalez-Pienda and Rosario
(2006) stressed that the information of the self-informs ought to be known by
whom is about to answer and, when increasing the knowledge on the less
visible observables (through a previous training) the subjects could observe
and to give answer of their own knowledge more objectively, so that the
results would be more accurate and would bring higher quality information.
More specifically, and attending to the employment way of the self-
informs, we found that in some described researches, the questionnaires were
employed at the beginning of the university’s stage. In this sense and, as
Chevalier, Parrila, Krista, and Deacon (2015) point out, the recorded data
would be informing about the strategies employed up to that moment; namely,
the ones employed during the previous years or during secondary school. In
other words, they would not be concurrent data, for they would not account for
the strategies used during the moment, that is, university’s stage. In the cases
where the metacognitive capacity was assessed during some task’s
performance, no simultaneous measures were considered, nor the analysis was
carried out at different time moments, as for instance at the beginning-ending
of the academic year, even though the literature has been evidencing the
improvement the result's robustness through a multimodal assessment and at
different time moments (Cerezo, Sánchez-Santillán, Paule, and Núñez, 2016;
Cromley and Azevedo, 2007).
CONCLUSION
Metacognition is perhaps one of the skills that contribute the most to a
quality learning (Monereo and Pozo, 2003). Inasmuch as we are aware on how
do we learn, what are our strengths or limitations, we can introduce some
degree of control on them and hence, we can improve them. Metacognition
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turns out to be a prerequisite “sine qua non” for self-regulated learning too
(Efklides, 2008). Learning which, on the other hand, has proven to be an

essential factor for the competence “learn to how to learn” (Cerezo, Núñez,
Fernández, Suárez-Fernández, and Tuero, 2011; González and Tourón, 1992).
The metacognition construct acquires even more importance when we face
to special collectives, as the students with learning disabilities (Suengas and
González-Marqués 1993; Wong, 1987). Alas, and in the light of the results,
there are few recent studies that approach the open question that we are
addressing. Although the landscape does not seem very cherishing, in the
descriptive-correlative nature studies, the relationship between metacognition
and effectiveness was supported and share by most of the authors. Even
though in some of these researches, it has been defined as predictive variable
for success (Trainin and Swanson (2005). This would be in concordance
with the few studies explored in this direction and which have explored the
possible factors of success in students, among others, self-knowledge and
skills required to take decisions were some of the essential elements to face
and endure before the demands from the secondary school (Field, Sarver and
Shaw, 2003; Getzel and Thoma 2008).
Therefore, although we now that metacognitive obeys a fundamental role
for an optimal learning and effectiveness, the question on how does not seem
to be clear for this particular collective (Trainin and Swanson, 2005). Looking
at the studies we find, on the one hand, subjects with disabilities that have a
low metacognitive capacity. This would support previous studies wherein the
metacognition plays a differential role, in the way that they allow to
distinguish between apprentices with and without learning disabilities
(Pintrich, 1994). On the other hand, and contrary to what it would be expected,
we have described previous studies whose results do not account for the
differences between subjects with an without learning disabilities, in what

metacognitive capacity is concerned. As a consequence, it has been proposed
an explicative hypothesis where metacognition assumed a compensatory
function, which, prior to the deficits associated to the specific difficulties, the
subjects could have developed their metacognitive capacity as an alternative
path (use of a wider variety, different or in greater way of the metacognitive
strategies). Nevertheless, the results on this regard are rather controverted.
Therefore, and turning to the proposed objective, that is, which function
has the metacognition on undergraduate students that undergo learning
difficulties? A clear and direct response seems not possible to be given.
Thus, in the aim to give a fair answer to the open questions and posed
problems, and taking into account the limitations that accompany the results
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found, it has been proposed for future researches a more thorough analysis and
assessment through the design or adaptation of the evaluation tools on real

time and the metacognitive processes prior to learning. This will enable to
improve their comprehension and be closer to the cognitive profile on adults
with learning disabilities and to develop suitable interventions and with some
empirical basis from where, the educative institutions and attention and
assistance services can attend the demands of this collective and hence,
adapt to the diversity of the student body. As Horowitz head of the SLD
Resources National Center for Learning Disabilities comments (2014):
“Learning disabilities are not a prescription for failure. With the right kinds of
instruction, guidance and support, there are no limits to what individuals with
SLD can achieve” (p. 3). It is well known that the metacognive skills can be
instructed or, at least that is what demonstrate some researches of the moment
(August-Brady, 2005; Printich, 2002; Rosário et al., 2007). Actually, from the
few studies at university degree, in which it has been carried out interventions
oriented towards the instruction of metacognitive strategies and academic
skills, the results are somewhat hopeful (Allsopp, Minskoff and Bolt, 2005;
Butler, 2003; Farmer, Allsopp and Ferron, 2014)
To end up, we ask ourselves what happens with the students when they
face the learning in virtual media. Linking this to what has been previously
commented at the very beginning, and taking into account that each time is a
used option, it seems to be an important question for their assessment and
study, in order to prevent possible learning difficulties inside this new context
of learning.
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Chapter 3
HEARING LOSS AND

INTELLECTUAL DISABILITIES
Siobhán Brennan1,2, and Sarah Bent3*
1
Audiology and Deafness, School of Psychological Sciences,
University of Manchester, England, UK
2
Regional Department of Neurotology,
Sheffield Teaching Hospitals, Sheffield, England, UK
3
Betsi Cadwaladr University Health Board, Wales, UK
ABSTRACT
There is a high prevalence of hearing loss in individuals with
intellectual disabilities and it can affect communication, personal
relationships and mental health. Awareness of this issue is increasing, as

is our ability to assess hearing and offer appropriate rehabilitation,
however significant developments in audiological care and management
are still required and further research needed. This chapter discusses
the importance of hearing loss identification and rehabilitation, aimed
at professionals across different disciplines and also as a starting
point for those new to the audiology profession. Various points on the
Audiological care pathway for people with intellectual disabilities are
presented including: identification of individuals who require hearing loss
investigation, methods of assessment of hearing loss, and appropriate
rehabilitation. This chapter includes the challenges faced by PwID and
*
Corresponding Author’s Email Address: Siobhan.brennan@manchester.ac.uk.
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62 Siobhán Brennan and Sarah Bent
hearing loss and by clinicians. The chapter will conclude with some of
the authors’ recommendations for improved Audiological care for PwID.
1. INTRODUCTION
Our relationship with sound is personal and unique. The impact
that hearing loss has on quality of life will vary enormously depending on
the person, but is known to potentially affect communication, education,
relationships and mental health. There is growing awareness of the importance
of hearing health in the general population internationally; however, this issue
is still under-recognised for those with intellectual disabilities. In this
population, not only is the prevalence of hearing loss greater but the impact on
life is too, particularly if not recognized; yet this is little known by those in
caring or other health roles. The authors aim to provide a summary of
the importance of hearing loss identification and rehabilitation, both for
professionals across different disciplines and as a starting point for those new
to the audiology profession.
This chapter discusses the points along the Audiological care pathway for
people with intellectual disabilities (PwID) including: identification of
individuals who require hearing loss investigation, methods of assessment of
hearing loss, and appropriate rehabilitation. This includes the challenges faced
by PwID and hearing loss and by clinicians. This is drawn from both peer-
reviewed and grey literature internationally, with additional recommendations
from the authors’ experience individually and as part of the UK special interest
group for professionals working in hearing and people with learning
disabilities, HaLD. The chapter will conclude with presentations of the
authors’ recommendations for improved Audiological care for PwID.
2. HEARING LOSS
According to the World Health Organization, there are currently 360
million people with disabling hearing loss globally (WHO, 2015). The
prevalence varies with country, but to take as an example the UK, hearing loss
affects approximately 1 in 6 of the population. Prevalence figures are
considerably higher in individuals with intellectual disabilities and higher still
with certain syndromes; however, there are significant limitations to this data.
This is partly related to the accuracy of hearing tests in the literature - some of
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Hearing Loss and Intellectual Disabilities 63
the adjustments that should be taken when testing hearing in this client group
are often not available. Many authors draw prevalence data from hearing
screening programmes carried out at the Special Olympics; this data is
restricted to individuals who are usually in good physical condition and often
with milder intellectual disabilities, and so possibly not truly representative
of the population as a whole. However, Hey et al. (2014) compared the
prevalence figures from the Special Olympics with that of the residents of a
school for individuals with intellectual impairment and found the 2 sets of
prevalence data very similar.
Despite this high prevalence, hearing loss is still not widely recognised.
As an example, one study suggested 70% of adults over the age of 40
with Down Syndrome to have significant hearing loss undiagnosed before
systematic hearing testing (Van Buggenhout et al., 1999). Possible reasons for
this are discussed further below.
2.1. Cause of Hearing Loss
The leading cause of hearing loss in any population varies by country due
to factors including general health, genetics and exposure to drugs and noise.
One of the primary aims of professionals such as Audiology or Ear Nose and
Throat teams, who see individuals referred with concerns about their hearing,
is to identify what type of hearing loss they may have. The type of hearing loss
will partly determine the most appropriate management, as there are simple
surgical and medical options available for some causes. Hearing losses can be
loosely grouped into conductive hearing loss and sensori-neural hearing loss
(or a mixed loss, which means there are multiple causes for the hearing loss).
This section outlines some of the more common issues that are identified as
causing a hearing difficulty in both the general population and those with
intellectual disabilities.
2.1.1. Conductive Hearing Loss

A conductive hearing loss is an issue that arises in the outer or middle ear,
so reducing the level of sound before it can reach the cochlea (the organ of
hearing). A very frequent cause of conductive hearing losses is earwax.
Individuals with intellectual disability as a result of a syndrome may have
narrow ear canals or dysmorphic ears that restrict the natural passage of
earwax. An additional aspect of narrow or tortuous ear canals is that otoscopy
(examining the ears visually) may not be achieved, as a clear view of the ear
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drum may not be possible. Excessive earwax affects approximately 2% of

the general population; in the population of individuals with intellectual

disabilities it has been found to be in the order of 30% (Crandell and Roeser,
1993; Smith et al., 2000). Long-standing impacted earwax can increase the
risk of infection, cause discomfort and result in or increase tinnitus (noises
experienced in the ears or head). Its presence will also prevent an accurate
hearing assessment. Earwax can be removed using a range of methods,
including softening (ear drops) which can be administered at home, and ear
syringing, manual removal or micro-suction by trained professionals. For
many with intellectual disabilities this is a simple process and, if checked and
acted on regularly, can be managed effectively. If a client is tactile defensive,
however, other approaches may be needed and working closely with carers
may enable the practitioner to provide appropriate adjustments. As standard,
hearing assessment appointment letters will often advise ear canals are
checked and any wax removed before attending. In the authors’ experience,
this advice is frequently not followed. A further referral to remedy this, such
as to an Ear, Nose and Throat department may be required, increasing the
number of visits and length of the care pathway. Foreign objects found in ear
canals may also cause hearing loss along with physical risks if not dealt with,
and should also be removed professionally.
Beyond the eardrum, the middle ear space should be air-filled, however
there are times when it can be filled with a fluid which stays for a long period,
commonly known as “glue ear.” Glue ear is very common in children. It can
also be present in adults, associated with temporary upper respiratory tract
infections, but will often drain naturally afterwards along the “eustachian
tube” into the back of the throat. There are often surgical solutions to longer
standing conductive hearing losses, such as insertion of small temporary tubes
known as “grommets” in the eardrums to drain the fluid. This is a simple
procedure which may be completed with local or general anesthetic although

that brings risks to those with other medical conditions, such as may occur in
those with syndromes. Due to these risks, an increasing number of patients
with this type of conductive hearing loss are opting for hearing aid use instead
of surgery, which will be expanded on later in this chapter. If not treated, there
is a possibility that glue ear can cause permanent damage to the ear (Balkney
et al., 1979) and consultation with an Ear, Nose and Throat specialist should
be sought in the case of longstanding glue ear.
The prevalence of chronic ear infections varies dramatically across the
world. According to the World Health Organization (2013) “over 90% of the
burden of chronic ear infections is borne by countries in the south-east Asia,
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western pacific and African regions, and ethnic minorities in the pacific rim.”
In addition to causing a hearing loss, chronic ear infections can lead to

other life threatening conditions. In the case of an individual who does not
accurately self-report, ear infections are more likely to be identified by family
members or carers than other causes of conductive hearing loss because there
is often a discharge or smell that can be observed. Also, this is more likely to
cause pain than other causes of hearing loss.
2.1.2. Sensori-Neural Hearing Loss

A sensori-neural hearing loss is the catch-all term for hearing losses that
affect the “cochlea,” or that affect the “auditory nerve.” Sensori-neural losses
are usually permanent with no surgical or medical interventions to resolve
them. They can be progressive. The most common form of sensori-neural
hearing loss results from damage to the cochlea, however it is estimated that
approximately 10% of sensori-neural hearing losses may be due to an
“auditory neuropathy spectrum disorder” (ANSD) (Uus and Bamford, 2006).
This term is used to describe a combination of Audiological findings which
would suggest good cochlear function but pathology of the auditory nerve,
distorting the signal travelling to the “auditory cortex” in the brain.
In some countries, for example the UK and the US, sensori-neural age-
related hearing loss (presbyacusis) is the most common cause of hearing loss;
as an example, Action on Hearing Loss in the UK report that the numbers
affected increases to over 40% of those over 50 years old and over 70% of
those over 70 years old. As human longevity increases, so the prevalence of
hearing loss will also increase. An increased prevalence with age has also been
observed in the population of individuals with intellectual disabilities. In a
recent review of the literature on this topic, Bent et al. (2015) identified studies
that reported on hearing loss prevalence with age. The prevalence of hearing
loss in adults with intellectual disabilities under the age of 50 was found to
range from 27% to 45%, and over 50 years of age from 59% to 68%
(Buchanan, 1990; Venhuis, 1995; Evenhuis et al., 2001; Meuwese-Jongejeugd
et al., 2006; Van Buggenhout et al., 1999).
2.2. Hearing Loss and Down Syndrome
While there are multiple syndromes which feature hearing loss and an
intellectual impairment, Down Syndrome has the highest incidence of hearing
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loss. The prevalence of sensori-neural hearing loss is higher in this group from
birth, and this incidence increases as the individual gets older. Age related
hearing loss is not only more common in Down Syndrome but also at an
earlier age, often by 20 to 30 years. Three studies looked specifically at the
prevalence of hearing loss in individuals with Down Syndrome, due to the
associated high rate of sensory issues and precocious ageing. For this specific
group under the age of 50, prevalence was reported from 38% to 76%, and for
those over 50 years of age, from 62% to 93% (Evenhuis et al., 2001;
Meuwese-Jongejeugd et al., 2006; Van Buggenhout et al., 1999).
Appropriate management will be discussed later in this chapter, but it
should be highlighted that ear wax is a particular issue for this group as ear
canals are typically narrow, so only a relatively small amount of ear wax is
sufficient to block the ears.
Additionally, for individuals with Down Syndrome, glue ear is much more
common than in the general population, due to a number of factors such as
narrower eustachian tubes and the middle ear fluid tending to be of a different
viscosity than in other people, taking longer to drain and more likely to
become infected (Sacks and Wood, 2003).
2.3. Hearing Loss and Other Causes of Intellectual Disabilities
There are many syndromes which commonly present with both hearing
loss and intellectual disabilities, including Down Syndrome, CHARGE
syndrome and Cornelia de Lange. In addition to syndromic causes, there are
genetic causes of the co-morbidities of hearing loss and intellectual
disabilities, such as chromosomal and mitochondrial disorders. There are also
a wide range of perinatal factors that can influence hearing and intellect,
including extreme prematurity and congenital infections. Some causes of
intellectual disability have specific types or patterns of hearing loss, or other
symptoms that are uncommon with other causes. It is beyond the scope of this
chapter to provide a thorough discussion of these factors.
Intellectual disabilities are usually present with multi-morbidities, some of
which will compound the impact of hearing loss and should also be taken into
account when the hearing is being assessed and managed. These are discussed
as relevant to each section.
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3. ACCESSING AUDIOLOGY SERVICES

Those with concerns about their hearing should seek help in order that any
pathology may be addressed, to understand what is causing the difficulties,
and to seek rehabilitation. Hearing loss which is not identified or managed can
have serious effects on communication, social activity and participation, along
with increased risk of depression and dementia (Action on Hearing Loss.,
2014). It is known that there tends to be a ten year delay in seeking help
for hearing in the general population (Davis et al., 2007); it is thought
to be worse still in those with intellectual disabilities. This may be in part
due to some carers’ lack of awareness of symptoms of hearing loss. Also, in
the case of adults with long standing undiagnosed hearing loss, if the
individual has developed an alternative form of communication that is
effective there may be a lack of interest in hearing assessment. Hearing loss
is as affected by diagnostic overshadowing as any medical condition, with
typical misconceptions being that lack of response to speech or an observed
behaviour change is related simply to a person’s intellectual disability.
3.1. Referral Pathways
If there are concerns about hearing, the starting point is to identify if

earwax is obstructing the ears, given the high occurrence as mentioned above,
and the ease of resolving this in the majority of people. Wax is a healthy and
normal part of the ear, and should not be ‘cleaned out’ by the individual or
family or carers; cotton wool buds and tips carry a warning in some countries
(e.g., UK) due to the risk of puncturing the ear drum and the abrasive effect
on the canal wall. Instead, ears should be checked regularly by healthcare

professionals in those with excessive production of wax, or those with ear
structure that prevents natural migration of wax out from the ear. Appropriate
advice on management can then be given.
However, when the ears are free from obstruction, further consideration
should be given to hearing loss in other parts of the ear. It should go without
saying that looking into the ears is only a small part of the hearing pathway,
and a referral to hearing professionals, such as an Audiology department
should follow. The authors’ experience is that regrettably it is a widely held –
but inaccurate – belief that hearing assessment is not possible with individuals
with intellectual disabilities. This belief is likely to be a contributing factor to
those with a hearing loss not accessing services. While modifications to
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standard hearing assessment is often necessary and there may be limitations to

the outcomes of such assessments, it is rare that hearing assessment of some

form cannot be achieved.
3.2. Screening
A majority of countries in the world now offer universal newborn

hearing screening, as this is widely recognized as the optimum time to
identify a hearing loss in the general population (Davis et al., 1997),
and screening checks available for this age are quick to complete.
However, this only identifies a proportion of permanent hearing losses and
progressive losses exist, so further hearing screening at later ages is usually
recommended. Hearing screening for adults continues to be debated (e.g.,
Lamb and Archbold, 2016; Pronk et al., 2011). There is arguably a strong case
for offering a targeted hearing screening to individuals with intellectual
disabilities in adulthood as the prevalence of hearing loss is so high in this
population. Also the impact of hearing loss is likely to be multiplicative
(Wiley and Moeller 2007). Furthermore, self-report may not be accurate for
individuals within this group (Emerson et al., 2013). At the time of writing, the
European Federation of Audiology Societies is working on recommendations
for screening this population (EFAS, 2015).
In the UK, an annual Health Check is offered to some adults with an
intellectual disability by their general practitioner, and includes a small section
on hearing and communication (RCGP, 2010). Despite the potential that this
routine targeted consideration of hearing should bring, the check currently
relies heavily on client and carer report, which has been found to significantly
under-identify hearing loss (Bent et al., 2015). It has also been suggested of
general practitioners’ role “Current training is not sufficient to provide the
skills for detection and management of hearing problems” (McShea et al.,
2015).
3.3. Suitability of Audiology Services
Hearing professionals’ services for PwID internationally tend to be

based either in hospital settings or community settings. Across the UK,
the services also vary by geographical location due to a range of factors
including differences in funding streams, overall departmental size, local staff
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experience and other demands on the service. While there are advantages in
services being standardized nationally, local differences in provision can be

beneficial if those differences are due to considerations of the needs of the
local population. Specialist services for those with a specific syndrome, Down
Syndrome for example, may have the advantage of being tailored for the needs
of those particular clients, but at the exclusion of others that could benefit.
Services offered for all those for whom standard Audiological care is not
appropriate are by design inclusive, but require highly skilled professionals in
their operation. Some have separate services for those with intellectual
disabilities from birth as opposed to those with cognitive decline relating to for
instance dementia, often due to the history of the creation of those services.
Coming to a hospital setting can be unnerving, to the point that an
individual may be so anxious that hearing assessment at that visit is not
possible. Audiology departments usually include sound proof rooms, for the
purpose of hearing testing accurately without interference from background
sounds; these are spaces that can be a strange experience for most
people. Time can be taken for the client to familiarize themselves with that
environment or a further appointment arranged.
3.4. Impact on Other Services
There are other services which have close relationships with audiology.
As well as the Ear, Nose and Throat team, a hearing assessment will often
have a major impact on the outcomes of Speech and Language Therapy and
Psychology. With regards to Psychology, the frequent relationship between
hearing loss and poor mental health is well established (Saito et al., 2010;
Monzani et al., 2008; De Graaf and Bijl, 2002; Cooper, 1976). This is
frequently due to depression arising from isolation (Matthews, 2013). An
increasing amount of research suggests that there may be a correlation
between hearing loss and cognitive decline, and at the time of writing, a
growing body of work is investigating whether therefore the use of hearing
aids slows this change (e.g., Ameiva et al., 2015). For individuals with Down
Syndrome, dementia often occurs earlier than in the general population (Van
Buggenhaut et al., 1999). This, combined with the early onset of presbycusis,
can have a multiplicative impact. There are strong arguments for a hearing
assessment being a standard part of the dementia test battery, and cognition
being considered alongside hearing assessment. As a minimum, links should
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be in place between services to ensure awareness and ease of referral in both

directions.
3.5. Considerations for a Specialist Service Model
Guidelines for Audiological Care for Adults with Learning Disabilities

(NHS Scotland, 2009) suggest that a specialist service should be available for
this group. Table 1 presents the authors’ suggested targets for inclusion in a
specialist service.
Table 1. Specialist Audiology Service Considerations
Service Choice  Specialised audiology service for individuals with intellectual

disabilities should be offered within a mainstream service and
with easy access to that service if preferred by the client.
Staff  Staff with training and experience in Audiological care for PwID.
 Clinic managed by 2 members of audiology team; however, for
those who prefer fewer people in the room, the option to be seen
by a single member of staff should be available.
 Continuity of care – the same clinicians to see the client
throughout their care as far as possible, to reduce anxiety for
clients who may find adaptation to change difficult.
 A dedicated co-ordinator responsible for evaluating and
developing the service and the introduction of initiatives.
 A named individual for each referral received who is responsible
to ensure their care is delivered.
Location  Access to the clinic room for orientation before the appointment
if requested.
 Home visits available if required.

 Private or alternative quiet waiting area available if required.
Equipment  All required equipment available at the time of the appointment
to reduce unnecessary additional appointments.
 Non-essential equipment cleared away as far as is reasonable to
reduce the sense of a “clinical” environment.
Time  Clinics on different days and times of day with a flexible booking
system, allowing the client to be seen at a suitable time.
 Longer appointments available, but staff aware of benefits of
keeping appointments brief.
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4. HEARING ASSESSMENT
There are multiple aims in hearing assessment. Some of the questions the
clinician hopes to answer include “What are the quietest sounds this person
can hear?,” “Can this person discriminate sound sufficiently to understand
speech?” but fundamentally “Does this person have sufficient hearing to lead
the life they want to lead?” Different tests carried out in an Audiology clinic
can contribute to answering these questions, ideally in conjunction with the
reported experience of sound from the client or carers. The priorities for the
assessment should be established early in the clinical encounter. The hearing
assessment battery should consist of multiple tests – each test represents
different parts of the hearing pathway and there are many instances where 2
people with the same single test result can ultimately have very different
hearing capabilities. Only collectively can the assessments inform the
Audiologist about the client’s possible experience of sound. In addition to
guiding the management process the hearing assessment can also provide an
opportunity to demonstrate to both the client and their carers the presence and
extent of a hearing loss. This is particularly useful as carers reports are known
to overestimate hearing ability (Bent et al., 2015) and a proficient hearing test
provides some level of clear evidence.
This section of the chapter aims to present a range of commonly
used clinical hearing assessments, their limitations and considerations when
being used to assess hearing for PwID. Recommendations for reasonable
adjustments are then suggested that could be used to address some of the
challenges of these tests.
4.1. Getting to know the Patient’s Auditory History
The extent of a hearing loss is often difficult to ascertain by any individual

themselves because they may be unaware of the sounds that they have missed.
Friends and family members may help to give a view of hearing abilities. This
is more so the case for individuals with intellectual disabilities, and family
or carers accompanying a client should be asked to report or clarify
on all aspects. The Cambridge-Calgary model could be used to frame the
appointment (Silverman, Kurtz and Draper, 2013). It is necessary to ensure
that possible responses to sounds are not, in fact, responses to accompanying
visual gestures or a client’s understanding of context. Offering a cup of tea is
frequently accompanied with a hand symbol of a cup, and an individual may
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be very aware that on walking toward a door it will be necessary to get ready
without ever hearing “please put on your coat.” It may be possible to glean
information on hearing from reported reactions to different types of sound.
Being more responsive to male voices might suggest that hearing is better at
low frequencies. Enjoying some music genres more than others may suggest
that there is sufficient hearing to identify the differences. Caution should be
used when drawing conclusions on hearing capabilities based entirely on
observation – for instance the teenager who turns music up may indeed be a
sign of deteriorating hearing, but may also be due to enjoyment commonly
gained from loud music. Table 2 presents some observations that may indicate
that someone should have a hearing assessment.
Table 2. Behavioral Indications of Hearing Issues
Behaviour directed  Puts 1 hand or both over each ear for no reason
towards ears  Bangs or slaps face
 Frequent touching of ears
 Unusual head movements
 Pulls ear lobes
 Cups hand behind ear
Auditory behavior  Developing behaviour that challenges
changes  Unexpected changes in behaviour
 Seems confused
 A lack of response to specific sounds
 Tends to respond more consistently to sound
presented on one side
 Attention span decreasing
Medical changes  Frequent catarrh (blocked nose)

 Discharge or smell from one or both ears
 Dizziness
The communication form that someone has chosen to use may be in part
due to an underlying hearing loss. Also, some forms of communication may
obscure signs of a progressive hearing loss – for example, with largely visual
forms of communication such as Makaton, responses to speech may not
change as dramatically as someone who relies on heard speech. While
understanding a client’s preferred form of communication is a fundamental
part of assessing the appropriate management, the reality is that audiology
clinicians with a working knowledge of communication methods such as
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Makaton, PECS and Objects of Reference are in the minority. Music is often
more motivating for people than speech. If someone is involved in music

therapy sessions, this may be an opportunity to more clearly identify
difficulties in hearing.
Attempts must be made to understand the communication needs of the
client, priorities of these needs, and how these fit into their wider needs. The
communication needs of people involved in the client’s life and their priorities
should also be taken into account. There are clients for whom all the
information typically gleaned from a hearing assessment will not be achieved.
For these clients, consideration has to be given to which aspect of their
hearing is most useful to understanding needs, and future rehabilitation
and management. The clients and their carers must be involved in this
prioritisation. As an example, some individuals are much more interested in
music than verbal speech. Should this then be used during the assessment?
Can rehabilitation be tailored to maximize music enjoyment over speech
discrimination? There are a range of methods used within audiology to record
priorities and extent of hearing difficulties being encountered by the patient in
situations they are typically in, with recent emphasis on goal setting, such as
with individual management plans, and associated outcome measures (BSA,
2012). These should be used before and after any rehabilitation.
4.2. Ear Health
In addition to understanding how well the client hears, the Audiologist is

also concerned with ear health. “Otoscopy” involves viewing the outer ear and
eardrum using a small light with a magnifier. This allows observation of issues
such as infection or earwax in the outer ear. It typically takes under a minute
in each ear. This is unobtrusive for many, but individuals who are tactile
defensive or dislike other people being in close proximity may find this
process uncomfortable.
4.3. Behavioural Assessment
While otoscopy and discussion with the client and those people closest to
them is the starting point of a hearing assessment, it is imperative that a
hearing assessment goes beyond this. Hearing can be tested in a range of ways
depending on aim of the assessment.
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4.3.1. Observation
During the initial discussion with the client and anyone they choose to
bring to the appointment it is a good opportunity for the Audiologist to
observe the client’s ability to hear the questions being asked and their interest
in conversation. This dialogue may be affected by level of comfort with the
situation in addition to their hearing abilities. Observations can also be carried
out at home and at day services to evaluate a client’s functional hearing, that is
how someone uses their hearing.
4.3.2. Audiometry
Pure tone audiometry (PTA) is a standard hearing test to identify the
quietest sounds that the individual can hear at a range of tones (frequencies).
These levels are then compared to levels expected in those with satisfactory
hearing. The client is asked to wear headphones and respond every time they
hear a sound which will vary in volume and frequency. The response is often
pressing a button, but where there are additional physical disabilities affecting
the response, the tester should use a creative approach to enable the patient
to respond comfortably and reliably. For an individual with an intellectual
disability, there are aspects of this test that may influence its accuracy:
Responses to No Sound
The test depends on an individual’s ability to wait. In the general
population people occasionally respond when there is no sound presented.
This risk tends to be higher for individuals with intellectual disabilities. This
may be due to lack of understanding of the need to wait for the sound or the
wish to “please” the tester by relating that they have heard a sound even when
this may not be the case. There are tactics that the tester can employ to identify
when this may occur such as lengthened and more variable gaps between
sound presentation, and lateralisation (“ear choice” audiometry (Lloyd and
Melrose, 1966)). Lateralisation in this context involves randomly changing the
ear that the sound is presented to and asking the client on which side the sound
is. For some individuals, this change of task is sufficient to improve the
accuracy of the test.
No Responses to Any Sound

While this might be due to the client having severe hearing loss, it is
usually known prior to the test whether this is likely from the clinician and
client conversation. Not responding to any sound can be due to reduced levels
of confidence. Frequent encouragement through the test can be useful. There
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are instances when the stimulus frequency changes, and the patient does not
react to this change immediately. The tester may then misread this lack of
response as a lack of hearing to this stimulus.
Starting and Not Finishing

It is necessary to test a range of volumes and frequencies. A client with an
intellectual disability may not react to stimulus change immediately. In this
instance the tester may misread this lack of response as a lack of hearing. This
can be accommodated by reinstructing when changing frequency. Shorter
periods of concentration may reduce test duration, so a smaller number of test
frequencies may be possible. The tester can extrapolate results to estimate the
remaining test frequencies if needed, however this has limitations in accuracy.
Also, carers or family members can help to identify the point at which
someone has stopped responding due to lack of concentration. The tester may
wish to divide the testing into separate sessions to address this issue.
Dislike of Headphones
For some people headphones are unpleasant to wear, particularly those
typically used in an Audiology clinic. Presenting the sounds through a speaker
(free-field), usually a hand-held device, can address this. This has the
advantage of accompanying family or carers being able to hear the levels of
sound at which the individual can hear, and the differences across frequencies.
The major disadvantage of this method however is that because the sound is
travelling to both ears, it is not possible to be sure which ear is responding.
If there are significant differences in hearing between the 2 ears, it may

indicate that further medical investigation is required. Aside from the medical
concerns that an asymmetric hearing loss raises, there are other disadvantages
in this type of hearing loss. While it is possible hear well with one ear, if
hearing is good in both ears it is easier to “localize,” or identify where a sound
is coming from. This has safety implications and can increase the feeling of
comfort in a range of situations. Another benefit of hearing well in both ears is
that hearing speech in background noise is improved. This is because the brain
compares the information from each ear, along with visual cues if we are able
to find the speaker and look at their faces.
4.3.3. Visual Reinforcement Audiometry (VRA)

For individuals who do not have the capacity to wait for the presentation
of a sound or carry out an agreed action, visual reinforcement audiometry is an
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option. During this test, a sound is presented through a speaker or headphones

and if the client turns towards the source of the sound there is an image of
interest to encourage them to continue to turn to sounds so that a range of
volumes and frequencies can be tested. Responses to sound in this situation
can vary widely and it is imperative that the tester and someone who knows
the client well work together to interpret reactions that the client may have in
response to sound. There are some who may not make the connection between
the sound presentation and the image, however in this case the tester and
family member or carer together can observe any responses the client makes to
presented sound. Examination of the outcomes of VRA testing at a specialist
clinic over the space of a year identified that responses sufficiently reliable to
draw conclusions about hearing status were found in a third of clients for
whom VRA was used (Dubb and Brennan, 2013).
4.3.4. Speech Discrimination Testing

In addition to identifying the quietest sound that a client can hear, it is
useful to identify at what level their hearing can discriminate speech. There are
a range of tests available which can consist of a word being presented and the
client being asked to either repeat the word or select it from a range of
pictures. There are very few tests of speech discrimination that have been
verified for use with adults with intellectual disabilities. This should be
taken into account when using this type of testing. The extent of the client’s
vocabulary should also be taken into account when selecting the most
appropriate test. If a presented word is not within the client’s lexicon they may
not respond at all or will respond with a similar word that is known to the
client and this could be mis-interpreted as a lack of hearing. Another risk of
this type of testing that it is often assumed that speech is the primary sound of
interest, however for some individuals this isn’t the case, and lack of interest
in the stimulus does not necessarily reflect the inability to hear that stimulus.
Additionally, speech tests are sometimes pre-recorded; if someone struggles to
recognize words spoken in an unfamiliar accent this can affect the accuracy of
the results.
4.4. Electrophysiological Assessment
There are also “objective” measures of hearing assessment. These are

ways of testing hearing that do not require an action from the client in
response to a presented sound. It is often used when behavioural assessments
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are not sufficiently repeatable. The majority of these tests can be carried out on
an outpatient basis, for which the client should be relatively still and quiet. If
this is not possible, some of these types of tests can be offered to take place
under general anesthetic; in which case there is benefit to completing on the
same occasion as any other procedures the client is to have which require a
general anesthetic.
4.4.1. Otoacoustic Emissions (OAEs)

Otoacoustic emissions are often used as a screening tool in babies and
younger adults. This test involves placing a small soft tip at the entrance to the
ear canal for approximately 2 minutes. A quiet sound travels as far as the
cochlea, and the normal hearing ear generates a sound of its own which is
recorded by a small microphone. The major advantage of this type of testing
is that it is ear specific and very fast. There are disadvantages however:
commonly recorded otoacoustic emissions are not frequency specific so
someone may have very good hearing at some frequencies but not others and
this will not be known. Additionally, this method only tests the auditory
system as far as the cochlea and no further, so if there are issues relating to the
auditory nerve this will also not be known. The test is only possible if
background noise is low – so this test is not appropriate for someone who has
perhaps involuntary vocalizations.
4.4.2. Auditory Brainstem Response Audiometry

Auditory Brainstem Response (ABR) testing involves placing electrodes
on the head to record the electrical signal travelling up the auditory brainstem
portion of the auditory nerve in response to sound presented via headphones.
To reduce the response being obscured by electrical activity from other parts
of the body the person being tested needs to be relaxed, and can be recorded
while the person is asleep. This test is ideal for hearing assessment under
general anesthetic. This test can be frequency specific and can take anything
from 10 minutes to an hour depending on how much information is needed
and how low the background noise is.
4.4.3. Cortical Evoked Response Audiometry

Cortical Evoked Response Audiometry (CERA) also involves placing
electrodes on the head to record the electrical signal travelling up the auditory
nerve in response to sound presented via headphones; however, due to the
nature of the stimulus and recording parameters used, the response recorded
originates higher up the auditory pathway. For this reason, this response is
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dramatically reduced if someone is asleep and therefore not suitable for

recording under general anesthetic. This test is also frequency specific and
again can take anything from 10 minutes to an hour depending on how much
information is needed and how low the background noise is.
4.5. Assessment Recommendations
 Ear canals should be checked regularly and impacted ear wax

addressed
 Family members and carers should be involved in the assessment
process
 The client should be able to visit the department before their
appointment and/or be provided with a story board of the
appointment. Images of the staff should also be available to see prior
to the appointment.
 A creative approach should be used when attempting behavioural
testing.
 The option of testing at the hospital or a home environment should be
available. There are major disadvantages to carrying out a hearing test
in a domestic environment; they are rarely sufficiently quiet, and not
all of the equipment is portable, limiting the testing that can be done,
however it may be much more palatable for the client than a hospital
setting.
 It may be necessary to use electrophysiology to assess hearing – these
techniques should be available and familiar to the tester.
 Research is needed to develop the accuracy and acceptability of
Audiological assessment for PwID. Urgent areas include;

 Optimising test parameters for electrophysiological testing,
 Verification of speech discrimination tests for PwID.
5. REHABILITATION
The impact of hearing impairment on each person is different. When
considering rehabilitation, there are a large number of factors which should
be taken into account. What are the forms of communication used by the
individual? Will the use of technology, such as a hearing aid, help or hinder
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that existing form of communication? Is the person with the hearing

impairment motivated to improve their hearing? The experience of activity

limitations and participation restrictions are equally important as the hearing
test in providing the effect and experience of that hearing loss. If an
amplification device is being considered, are there barriers to its use, that taken
into account with the benefits would result in an overall decrease in quality of
life? What reasonable adjustments could be considered to facilitate hearing aid
use? Are there equitable alternatives?
5.1. Hearing Aids
Like so many areas of applied science, hearing aid technology is

developing at a prodigious rate and satisfaction with hearing aids has increased
over recent years. Hearing aids have been shown to improve outcomes for
PwIDs as well as the general population (Cupples et al., 2013). Wearing a
hearing aid is not equivalent to wearing glasses. Whereas glasses will return
most wearer’s vision to an experience very similar to that of a non-glasses
wearer, the same cannot be said for hearing aids and the hearing impaired
listener. When hearing is impaired, sound is not only quieter, but in most cases
also distorted to a certain extent.
The uptake of hearing aids is influenced by a great many factors – some
intrinsic to the hearing aids, and some intrinsic to the wearer. Often factors
which influence the likelihood of an individual seeking help are also those
which impact the likelihood of success with hearing aids when they are issued.
Factors external to the hearing aids include self-confidence about ability to
manage the hearing aids and support of significant others. Taking the group as
a whole, it has been found that the expectations and wishes around hearing
aids by individuals with intellectual impairment are similar to those of the
general population, including sound quality, cosmetics and comfort
(Meuwese-Jongejeugd, 2007).
5.1.1. Setting Hearing Aids

The most common hearing aids are Behind-the-ear (BTE) and In-the-ear
(ITE). The BTE consists of an earmould which fits in the outer ear and directs
amplified sound into the ear from the main body of the hearing aid which sits
behind the ear in the same location as a glasses leg/arm. Earmould selection
will depend not only on the Audiological needs of the patient but also the
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nature of their external ear. A significant proportion of individuals with

intellectual disabilities have cranio-facial abnormalities and a higher

prevalence of canal stenosis than the general population. Canal stenosis is a
narrowing of the ear canal. In addition to often being smaller, the external part
of the ear in individuals with Down Syndrome has been found to be softer and
shallower than in individuals without Down Syndrome (Miller, 1997). An
implication that this has been found to have on hearing aid uptake in this
population is the frequency with which the hearing aid will fall from the ear.
The ITE however is a single entity which sits in the outer ear and tends to
be more appropriate for mild and moderate losses than severe or profound
hearing loss. Additionally, considerations around which to select include ease
of insertion, likelihood of loss and risks of ingestion.
The outcomes of the hearing assessment are used to program the hearing
aids using “prescription formulae.” These use group data to predict the hearing
aid settings that will maximize clarity of speech. The fact that group data is
used means that for an individual the optimum settings may be significantly
different. Evidence is currently limited regarding the optimum approach to
take in hearing aid fitting and management for adults with intellectual
disabilities, for example at the time of writing the standard prescription
formulae have not been validated in this group. For these reasons, once a
hearing aid is set up, the wearer is asked their opinion regarding the quality
of sounds, and “aided” speech discrimination tests too. Hearing aid fine
tuning can then be carried out accordingly. For individuals with intellectual
disabilities, communicative skills may not be sufficient to articulate their
opinion on this. Also, questions directed to the wearer should take into account
the increased likelihood of acquiescence in individuals with intellectual
disabilities.
Programming the hearing aid often requires making Real Ear Measures
(REMs). This involves placing a small tube in the ear canal with the hearing
aid in place to measure the sound. Placing an identical hearing aid on 2
different ears can sound very different - imagine how different your voice
sounds in a cave to how it sounds in your living room! If a client has too much
involuntary movement or earwax to make this a safe procedure the hearing aid
can be set up in a coupler (a small tube which imitates an ear) using average
data called “Real Ear to Coupler Difference (RECD).” However, there are
syndromes associated with intellectual disabilities and hearing loss such as
Down Syndrome which present with smaller external ears than expected and
the standard RECD may be inaccurate. For these individuals, coupler fittings
may be inaccurate. How someone perceives familiar voices will be more
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crucial than their perception of the Audiologist. Additionally, it can take

longer for an individual with an intellectual disability to acclimatise to the

voices of people who they are not familiar with. The family member or carer
accompanying the client can be involved with establishing whether or not the
hearing aid is making a discernable difference to their communication. This
could include presentation of different environmental sounds that the client is
familiar with presented at different levels.
Multiple programs can be incorporated allowing the user to adjust the
hearing aid settings depending on the situations they happen to be in. It is
thought that the use of additional hearing aid programs should be removed
unless a user has full comprehension of their appropriate use. This may be less
of a need as hearing aids are developed with increasingly sophisticated ways
of self-adjustment with scene analysis.
5.1.2. Adapting to Hearing Aids

Time is required for an individual to acclimatise to a hearing aid, and for a
person with an intellectual disability the introduction of change can be
particularly stressful. It is essential that careful consideration and treatment
planning is put into place to ensure that the potential benefits of amplification
can be gained by those who wish to use them. There may have been an
extended period of time between developing a hearing impairment and using
hearing aids, as there is a higher incidence of long term undiagnosed hearing
loss in this group. The introduction of amplification may be an unsettling
experience. If this is not managed appropriately there is a high risk of the
patient rejecting amplification entirely. For these reasons in the case of a
bilateral hearing loss (in both ears) there is an argument that the first hearing
aid fitting should be a unilateral fit (hearing aid for one ear only), and only
once it is established that the patients enjoys the use of the hearing aid and gets
benefit from it, should a second hearing aid be considered.
Hearing aids are becoming much better in terms of their ability to cope
with music. It should be explored at the point of assessment whether the client
has an interest in music, so that this can be taken into account in the hearing
aid fitting. This could be a stimulus that is used to develop a person’s
relationship with their hearing aid.
The uptake of hearing aids is known to be poor in individuals with
intellectual disabilities if there is insufficient provision of adequate support
and follow-up. Review appointments are to assess the outcomes of hearing aid
use after it has been worn for a time. In addition to the identification of any
logistical issues, discussions should also focus around particular parts of a
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person’s life where they found the hearing aid of benefit or that it caused
specific difficulties. “Datalogging” is a feature that allows the Audiologist to

discover how frequently the hearing aid has been on. For individuals with
multiple programmes and an adjustable volume control, datalogging can also
reveal user preferences and indicate whether, for example, the user needs more
gain if there is evidence that the volume is repeatedly being turned up. It may
take repeated review appointments for a client to fully adapt to hearing aid use.
Some issues relating to rejection of hearing aids may be related to clients
and/or their carers not being confident in their use. This can occur in larger
institutions where instructions have been issued to a single carer on the date of
the hearing aid fitting and that information has not been effectively passed on
to the other members of the patient’s care team. This can be addressed by
additional training sessions being offered to clients and staff which include
reiterating the benefits of a hearing aid for a client with an intellectual
disability and hearing loss, insertion and removal of the hearing aid,
maintenance including cleaning, battery replacement and trouble shooting.
5.2. Alternative Rehabilitation
For those clients for whom hearing aids are not wanted or appropriate,
there are still many benefits of hearing assessment. If the client and their
family or carers are aware that there is a hearing issue, a greater amount of
support can be offered and hearing tactics can be developed. Also there are a
wide range of adaptations and assistive listening devices available, such as
connecting fire alarms to the lights, or amplified telephones. The form of
communication that someone uses should be considered within the context of
their hearing loss.
5.2.1. Hearing Tactics

Hearing tactics refer to strategies that an individual can use to maximize
the clarity of the signal being listened to. These tactics make hearing easier for
most people, with or without a hearing loss. Training in using these tactics
would benefit in particular those who have a hearing loss, but are unable or
choose not to wear a hearing aid. For example, Action on Hearing Loss
recommended tactics for the listener include:
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 Looking at the speaker

 If there is a difference between the ear moving the better ear toward
the speaker
 Make the speaker aware of a hearing loss
Tactics for the speaker can include:
 Getting someone’s attention before speaking

 Don’t cover any part of the face or exaggerate facial movement
 Reducing background noise
There are many more tactics that can assist the listener with a hearing
impairment. If a client works with multiple of carers, it would be useful for all
of these carers to become familiar with them.
5.2.2. Assistive Listening Devices

In addition to hearing aids, there are a wide range of devices that can be
used to complement hearing aid use and others which can be used entirely
independently. Devices which can be used with or without hearing aids
include loud doorbells, telephones or TV listeners which may use headphones.
The form of communication used by an individual with an intellectual
disability and whether they are tactile defensive and can tolerate headphones is
likely to influence which devices are most appropriate.
If a client uses hearing aids, there are also devices that work with the
hearing aid to reduce the impact of background noise. These include frequency
modulation (FM) systems. These generally consist of a microphone which is
placed as close as possible to the speaker and the signal is transmitted like a
radio signal to the hearing aid. FM systems can be either personal FM systems
where the speaker may wear the microphone such as in a classroom setting, or
FM systems which have a fixed microphone to help in a public setting, such as
a bank or theatre. When the user has an intellectual disability care it may be
necessary for the individual or anyone supporting them to become familiar
with these devices. In some countries these devices are offered through social
care services or 3rd sector voluntary organizations. New technology is also
becoming available rapidly, including wireless and Bluetooth options for
connecting hearing aids to the client’s own personal technology such as
telephones.
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5.3. Rehabilitation Recommendations

 Regular wax monitoring and removal at the GP surgery or Ear Nose

and Throat department is recommended for PwID.
 Hearing aid checks relying on questioning should be done with
caution in light of possible acquiescence. Measures of hearing aid
levels by audiology are recommended instead.
 A range of communication devices should be available alongside
hearing aids.
 Hearing tactics should be offered to both PwID and their carers.
 In coming to terms with using and hearing through the hearing aid,
both the individual’s and their carers’ needs should be considered and
supported.
 Prior to any demonstration and instructions, patients should be
advised on becoming accustomed to the hearing aid, being counselled,
encouraged and reassured.
 Both patients and their carers should be provided with verbal and
written information as appropriate.
 Other professionals relevant to the individual’s care should be
considered, such as Hearing Therapy or Speech and Language
Therapy specialists.
 Prior to routine monitoring a rehabilitation pathway should continue
until the clinician is confident that the auditory needs are realistically
met, and that the patient and their carer are having no major practical
difficulties with hearing aid use.
 Greater research is needed surrounding Audiological management for
individuals with intellectual disabilities. This research should include;
 comparing the outcomes of different service models,

 verification of optimising hearing aid fitting targets for PwID,
 appropriate outcomes for assessing when individualised needs are
met.
CONCLUSION
Regrettably, hearing loss is one of the many health issues that is under-
identified in individuals with intellectual disabilities. Even if suspected, the
effect of hearing loss is often underestimated or not prioritised. As
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longevity increases, the prevalence of hearing loss across the population

as a whole increases and demands on Audiological care also increase. The

need for improved access to appropriate hearing assessment and personalised
Audiological care is widely recognised. While there are additional challenges
to accessing and utilising audiology services for individuals with intellectual
disabilities and hearing loss, this chapter had outlined many steps known
to minimise these, and the benefits for most people outweigh the issues.
As health and hearing screening programmes continue to expand, the
opportunities for accessing audiology services increase. Awareness of sensory
needs is increasing.
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PSYCHIATRY - THEORY, APPLICATIONS

Additional books in this series can be found on Nova’s website

Additional e-books in this series can be found on Nova’s website

NOTICE TO THE READER

JOINTLY ADOPTED BY A COMMITTEE OF THE AMERICAN BAR ASSOCIATION AND A

Library of Congress Cataloging-in-Publication Data

Library of Congress Control Number: 2016946651

Published by Nova Science Publishers, Inc. † New York

and Hearing Loss 91

Chapter 7 Integrating Students with Disabilities in Academia:

A Rewarding Challenge 173

This book contains assessments, management options and challenges

Chapter Six discusses the impact of challenging behaviour on families and

regarding the nosological status of learning disorders is very controversial,

differences in metacognitive ability of college students when compared with

training. Follow up visits were made to each home and a reassessment of

underestimation of hearing loss in people with learning disabilities and

phonological analytic instruction was more beneficial to students with surface

THE NOSOLOGICAL STATUS OF

Júlia Beatriz Lopes Silva1, 2, Ricardo Moura2

conditions in which there is a discrepancy between school achievement

neurobiological basis of dyscalculia being quite recent compared to

research on other learning disabilities, there is current evidence

Keywords: dyscalculia, nosology, diagnostic

THE NOSOLOGICAL STATUS OF DYSCALCULIA

underlying neurocognitive mechanisms related to DD. Interestingly, regardless

“pure forms” of the disorder, related to deficits in basic numerical abilities

DEFINITION AND DIAGNOSIS OF DYSCALCULIA

daily life activities which require number manipulations. Those difficulties

Dyscalculia screener that aims at identifying dyscalculia, and to separate it

from the other causes of poor numeracy attainment by means of a timed-based

difficult to implement. Moreover, there are currently no generally accepted

identify children and adolescents with DD or mathematical learning

PREVALENCE AND COMORBIDITIES

specific, once the probability of having dyscalculia in a family with

dyscalculia is higher than having dyslexia. Besides that, questionnaires

genetic-molecular and neuroimaging research, are arousing interest on

The etiology of DD is probably multifactorial, being associated

performance, such as intelligence (Strømme and Magnus, 2000) and working

NEUROBIOLOGICAL AND COGNITIVE MECHANISMS

be able to perform mental calculations, learn the multiplication table, convert

between Arabic and verbal numerals, counting and representing numerical

a) Approximate Number System Acuity

The approximate number system (ANS) is a built-in cognitive process that

the acquisition of symbolic representations of numbers, thus allowing the

the core deficit in dyscalculia.

Working memory (WM) is involved in different abilities, among them,

acquisition and consolidation of arithmetic facts. In a longitudinal study, it was

Phonological processing is traditionally associated to reading and writing

Regarding number transcoding, specifically Arabic number writing, the

input is verbal, hence one must be able to differentiate between sounds of

As explained before, the internal representations of numbers is considered

comparing the SNARC effect exhibited by children with combined numerical

Another source of evidence for an association between visuospatial

abilities and arithmetic in children comes from the neuropsychological

induce an improvement on basic and also on more complex mathematical

children with previous high performance on a variety of number tasks,

Kucian and coworkers (2011) evaluated the efficacy of a computer-based

training program on DD rehabilitation by means of neuropsychological testing

study by Gilmore and coworkers suggests that nonsymbolic approximate

of the several endophenotypes, their contribution to the disabilities and neural

Bruandet, M., Molko, N., Cohen, L. and Dehaene, S. (2004). A cognitive

Fawcett, A. J. and Nicolson, R. I. (2001). Dyslexia: The role of the