Making the Grade

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Kennedy Krieger Clinic Evaluates College-Aged Students with Learning Disorders

As soon as Joshua Fine reached pre-school, his mother Kathleen noticed that he learned differently from his older brother. As he picked up his ABCs and began trying to piece words together, Josh often reversed the order of his letters. This tendency continued as Josh began elementary school, but never reached a crisis point. Although Josh frequently refused to read, his grades stayed adequate. But Kathleen harbored nagging suspicions that her son wasn't reaching his full academic potential.

Josh's problems escalated in high school as reading, writing and foreign language assignments grew more and more complex. In his freshman year, a psychologist diagnosed Josh with both auditory processing and written expression disorders, but his public school would not provide any accommodations for course work, testing or other assistance unless Josh enrolled in a special education program. He chose to remain with his friends in mainstream classes, got decent grades and SAT scores, stayed active in sports, and gained admission to Mount St. Mary's College in Emmitsburg, Md. That's when the bottom fell out. Josh's grades plummeted, endangering his position on the school's Division I lacrosse team and his enrollment at the university.

"He was so proud of making it through high school and getting in to Mount St. Mary's without relying on a lacrosse scholarship," says Mrs. Fine. "He wanted to continue doing it on his own, and ended up having a very rough year he almost couldn't come back." College counselors suggested that Josh, 19, come to Kennedy Krieger's College Clinic for evaluation at the start of his sophomore year.

Most of Kennedy Krieger's programs focus on the needs of children with developmental disabilities, but the Institute recognizes that challenges don't disappear when someone turns 18. That's why the Institute's Center for Development and Learning established the College Clinic, an eight-year-old program that evaluates students in their late teens through their mid-20s for attentional and learning disorders and recommends accommodations that help them meet their academic goals despite their disorders.

Although many learning disorders surface in the first few years of school, the heightened pressures of college and graduate school can intensify known disorders and make previously undiagnosed disabilities more obvious. "Until college, students have parents keeping after them to make sure they're doing their homework and preparing for exams," says Dr. Marjorie Fessler, supervisor of Outpatient Educational Services in the Center for Development and Learning. "They don't have that support when they get to college, and there's the added temptation to participate in many more social activities and higher-level athletics on top of new demands for independent living skills, such as bill-paying and doing their own laundry and cooking."

Mount St. Mary's welcomes a freshman class of about 325 each academic year, of whom perhaps 25 have diagnosed learning disorders. But Denise Marjoram, Director of Learning Services at the college, refers 12 or so students per year for evaluation. "These are students who managed to keep up with the work in high school by spending 10 hours a day on it," she says. "To keep up with the degree of work in college would take 20 hours a day, which just isn't possible."

In addition to their increased academic rigor, the structure of college classes can prove daunting as well. Unlike high school classes, where teachers collect daily assignments and establish regular preliminary mileposts for longer-range projects, college professors often require one paper to be turned in at the end of the semester and expect the students to manage their own time well enough to complete it. Such an open-ended assignment can spell disaster for a student with a learning or attention disorder.

"These students typically have trouble with multi-tasking, planning, and organization," says Dr. Fessler. "They may be able to procrastinate, pull an all-nighter, and get an A on a single short paper because they're often very bright, but they can't do that on a lengthy term paper or if they've got three final exams and two papers due within a few days."

That mirrors Josh Fine's experience. He failed a Spanish class his freshman year, but spent this past summer retaking it at a community college. He earned a B. "If I'm only taking one class, I'm fine," he says.

While Josh managed to keep up with his high school classes through rote memorization, he found that strategy useless at Mount St. Mary's, where students must complete an extensive core of philosophy and other humanities classes. These classes focus on interpretation of complex readings and highly-reasoned essays, not absorption of facts. "They told us there was no right answer," says Josh, "and memorizing those is how I got by in high school. Here, the professors write one word on the board and talk around it and expect you to find the point on your own it's very easy for me to lose focus. I never know what I'm supposed to write down."

That inability to extract the meaningful elements of a discussion is known as an auditory processing disorder. Students with such a disorder can often be helped by accommodations such as note-taking support, which provides a backup set of notes for studying. Schools that accept federal funds must provide accommodations, but require documentation of a student's disability to assure that they are warranted. Most also require the documentation to be no more than three years old, so a student diagnosed with a learning disorder in high school or earlier will probably need to have an updated evaluation to document the need for accommodations in college or graduate school. Besides note-taking services, accommodations such as a quiet test environment, extended time for exam completion, and single dorm rooms are other ways students are supported.

Like all Kennedy Krieger programs, the College Clinic follows an interdisciplinary model. Students make two clinic visits. On the first, they meet with Dr. Thomas Ley, a senior psychologist in the Neuropsychology department, for a half-day session. Dr. Ley administers an IQ test, processing and attentional measures, and screenings for emotional symptoms to determine whether factors such as depression might be contributing to a student's academic difficulties. Later, the student returns for a half-day session with Dr. Fessler, who performs graphomotor, reading, math and written expression assessments. The doctors also collect other information besides the test data. When possible, Drs. Ley and Fessler interview their clients' parents to find out when difficulties first surfaced and how they've progressed over the years. "In addition to obtaining a comprehensive history and reviewing school records and reports from prior evaluations, we take into account the qualitative aspects of the student's test performance," says Dr. Ley. "For example, we note things such as error patterns and attention to details, the student's approach to different task demands, the need to repeat test questions or instructions, and variability in performance on some tests that is often associated with lapses in attention."

The resulting analysis is much more precise than any that could be drawn from a student's standardized test performance, says Dr. Fessler. "Because the tests are given on a one-to-one basis, we have the benefit of being able to observe students' behavior and see how they approach tasks. We could identify a problem as simple as working from left to right in subtraction or could pinpoint one as complex as a specific type of error pattern in their reading decoding skills," she says.

Drs. Fessler and Ley use the assessments to gauge the presence and degree of the students' learning and/or attention disorders, as well as to identify measures that could help the students meet their goals. "We integrate the qualitative findings with the test data to help substantiate the presence of a disorder and develop detailed recommendations and specific accommodations for the student," says Dr. Ley. For some students, those measures may involve taking medications such as Ritalin that can help them to focus better on the tasks at hand. Other students may require accommodations at their schools or when taking standardized tests such as the SAT, GRE or MCAT. Drs. Ley and Fessler have also recommended provision of assistance and support for organization, writing, course selection and balancing, and study skills.

In Josh's case, the doctors confirmed his earlier diagnosis of a disorder of written expression and also identified a reading disorder, graphomotor disability and ADHD NOS, or "not otherwise specified." This diagnosis means that while Josh exhibits a number of significant symptoms as well as more subtle signs of ADHD, he doesn't meet all of the criteria. Drs. Ley and Fessler developed a wide spectrum of accommodations to help Josh meet the requirements of his college program. In addition to taking Ritalin or a similar medication, they recommended he contact the Mount St. Mary's Learning Services department to arrange for help with his written assignments, starting with the planning process and continuing through final edits. He should also receive priority registration for classes and advice on course balancing to ensure he gets into the classes he needs and doesn't sign up for an overwhelming or inappropriate mix of courses.

They also recommended organizational support to help him structure his time and set timelines for long-range assignments. Josh is also eligible for testing accommodations: extra time, a smaller, quieter testing environment, and occasional breaks. To help compensate for the graphomotor disorder essentially, difficulty with handwriting Josh should have access to a computer, dictation equipment, or scribe services. Books on Tape should also be made available. Many of the texts Josh uses may already be available on tape in the Mount St. Mary's library. Others may have to be obtained through Recordings for the Blind and Dyslexic or made available through software that scans and verbalizes the text.

Drs. Ley and Fessler also recommended Josh use a Palm Pilot or similar device to stay organized. "They're really easy to work with you can carry one around in your pocket and enter appointments and due dates as soon as you hear about them," says Dr. Fessler.

The College Clinic staff stays current on strategies and tools students can use to help themselves. They suggested that one former client who was struggling to organize a major research project purchase a specific software package that would assist her in integrating her information. Their suggestions have helped past College Clinic clients achieve success in their academic careers. One student referred to the clinic, after ending up on academic probation, later gained admittance to a graduate program in architecture. Another is currently considering medical school as an option. A third spent last year abroad on a prestigious Fulbright scholarship.

The College Clinic expands on the Center for Development and Learning's core goal of helping children from preschool through adolescence triumph over problems in language development, learning, behavior and school adjustment. Using an interdisciplinary approach, the CDL relies on the work of physicians, nurse practitioners, social workers and educators to provide evaluation, counseling and, when appropriate, medical management for children with learning and attention disorders. In some cases, children come to the CDL while still in preschool because parents or teachers have observed difficulties in language development, attention or other learning skills.

This opportunity for early intervention is valuable the earlier a learning or attentional disorder is identified, the easier it is to begin appropriate interventions and minimize a disorder's impact on a child's social and academic development. Often, the CDL works with families in obtaining the school services and accommodations to which their children are entitled.

Dr. Fessler sees these interventions as necessary instruments to help compensate for a disability, just as reading glasses assist individuals with impaired vision. "These accommodations don't offer an unfair advantage they just level the playing field," she says.

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