Jan 29, 2015Lost in Learning
If you treat school-age athletes, chances are you work with at least a few who have learning disorders. By understanding their unique challenges, you can adjust your approach to better meet their needs.
By Laura Ulrich
Laura Ulrich is a contributing writer for Training & Conditioning. She can be reached at: [email protected].
It’s Monday morning, and a wrestler comes into your athletic training room nursing a sore knee. You help him onto the treatment table and begin your assessment: “When and how did the injury happen? Does this motion cause pain? How about this one?”
The questions seem clear to you, but the athlete’s answers are frustratingly vague. He can’t tell you how long he has been in pain, and when you ask whether he has ever injured the knee before, he doesn’t give you a clear answer. Mostly, he mumbles “yeah” to whatever you say, making a thorough assessment a real challenge.
You do the best evaluation you can and move on to creating a treatment plan. You decide to keep him out of practice for a week, assign him some stretches, and have him ice the knee three times a day, 20 minutes on and 20 minutes off. You ask him if he understands your instructions and get another “yeah” before he quickly heads out the door.
Two days later, you check in with the athlete. When you ask how the icing is going, you get a blank stare before he says, “It’s okay.” When you ask him to show you how he’s coming along with the stretches, he can’t recall how to do them, and you soon realize he hasn’t complied with any part of the treatment plan.
Your next thought is probably, “How utterly aggravating!” You may also be angry at the student-athlete, since you’ll have to start over from square one with him. But would your thoughts differ if you knew he had a learning disorder?
They should, according to Rick Lavoie, MA, MEd, veteran special educator, who is one of the nation’s leading advocates for children with learning disorders and the author of several books and videos on the topic. “Go back to that initial conversation with him,” Lavoie says. “This time, imagine that while you’re talking to the athlete, you can’t use any words containing the letter ‘N.’ At the same time, imagine that as the athlete talks to you, he has such a strong foreign accent that you can only understand every third word. Now you’re starting to see what the conversation was like for the athlete–and why he wanted to leave as soon as he could.”
Studies have found that 10 to 15 percent of school-age children are diagnosed with learning disorders, which means many will visit your athletic training room. Without the right approach, your work with them can result in frustration and miscommunication, as well as disappointing treatment outcomes. With the right approach, however, you can help these student-athletes thrive.
DEFINING THE DIAGNOSES
Learning disorders are usually categorized into two groups: attentional disorders and learning disabilities. Attention deficit hyperactivity disorder (ADHD) falls into the first category and is not technically a learning disability. However, it’s estimated that half of all children with ADHD also have a specific learning disability.
Until 1994, ADHD was called attention deficit disorder (ADD). That designation is no longer used, and instead, professionals diagnose three subtypes of ADHD. Individuals with “inattentive type” ADHD have trouble with details and focusing. Those with “hyperactive-impulsive type” cannot remain physically still and may talk and interrupt excessively. Those with “combined type” exhibit elements of both.
Learning disabilities, meanwhile, relate to problems processing certain kinds of information. “A person with a learning disability has an average or above average IQ, but a specific roadblock exists in their brain,” explains Pat Monroe, MEd, CAGS, School Psychologist and Director of Special Programs at South Allegheny High School in McKeesport, Pa., who also serves as the school’s Head Football Coach. “The roadblock causes certain types of data to get lost or scrambled.”
Most professionals group learning disabilities into three basic categories. Students with a:
Reading disability have trouble decoding or recognizing words. They may also have difficulty with reading comprehension and be unable to remember basic facts, main ideas, or themes. Dyslexia is one type of reading disability.
Written-language disability have difficulty with handwriting, spelling, sentence structure, word usage, and putting their thoughts into writing. It’s common for a child to have both reading and written-language disabilities, since both are language-based. These individuals may also struggle to absorb information when it’s presented verbally, something known as an auditory processing problem.
Math disability have difficulty differentiating numbers, recalling math facts, writing numbers legibly, and relating math facts to meaning. They may also struggle with abstract reasoning.
Learning-disabled students who fall into any of these three areas can sometimes have problems with short-term or “working” memory. Another challenge for learning-disabled individuals is metacognition–the ability to think about how they’re thinking. Without this skill, they have trouble devising effective strategies for learning and recalling new information.
What do learning disorders look like in the athletic training setting? An athlete with a learning disability may have trouble following directions. They may be unable to process data related to numbers, such as times, sets, or reps. They may also be unable to make sense of written instructions, so the great handout you gave them on back stretches ended up crumpled at the bottom of their locker.
Athletes with attentional disorders also can have difficulty absorbing information–not because they have a processing problem but because they can’t listen or focus long enough to get the entire message. “The individual with ADHD over-attends to everything,” says David Csillan, MS, ATC, Athletic Trainer at Ewing (N.J.) High School. “When you’re showing them a rehab exercise, they’re noticing everything else in the room–the chart on the wall, other athletes, and the music on the radio.”
Because learning-disordered athletes absorb and process information differently than other athletes, the first step to working with them successfully is to take extra care with communication. You may need to find new ways to relay instructions or use nontraditional strategies for getting their feedback.
Mark Szafnicki, MEd, Athletic Director, Head Tennis Coach, and reading teacher at the Gow School, a school for boys with learning disabilities in South Wales, N.Y., uses a three-pronged approach to communicate with his athletes. “We use the acronym VAK, which stands for visual, auditory, and kinesthetic,” he says. “If you’re teaching an athlete an exercise, you need to demonstrate it visually and explain it in words. Then you need to make sure they physically carry out the movement correctly while you are there to help–that is what will make it stick in their mind.
“Most non-learning-disordered athletes can get by with just the auditory input,” he continues. “You can tell them, ‘Lift the weight further in front of you,’ or ‘Throw the ball 10 yards further down the field.’ But learning-disordered athletes really need the other two forms of communication, too.”
It’s also important to avoid giving learning-disordered athletes a lot of information at once. “When a non-learning-disordered athlete comes in, I might say, ‘Go over to the rack and grab a two-pound weight and do straight-leg raises. When you’re done with that, do one set of 10 hamstring stretches, and then call me,'” Csillan says. “If I say that to a learning-disordered athlete, they’ll probably go over to the rack, grab a seven-pound weight, and stand there and look at me. So I make sure I give one instruction at a time.”
Repeating information can also help. “We go through the same set of stretches every day in tennis practice, but every day, I demonstrate how to do them correctly,” Szafnicki says. “Not every athlete needs to hear it again, but I know there are some who do.”
When communicating with athletes who have attentional problems, it’s important to consider the setting. “It really helps to treat them in an environment with fewer stimuli,” Csillan says. “That can mean asking them to come in early or setting them up in a quiet corner.”
Getting your messages across to the athlete is only half the job. Eliciting the information you need can be equally challenging. Athletes with learning disabilities may not provide any indication they don’t understand what you’ve said or asked. “They have very sophisticated ways of making it look like they understand when they don’t,” Lavoie says. “They’re usually not going to tell you when they’re struggling. They’ll nod like, ‘Okay, I’ve got you now,’ and then do the exact opposite of what you said.”
Monroe suggests asking them to repeat what you said or demonstrate it physically. “But be careful how you do this,” he cautions. “Respect their dignity and keep in mind that you’re not dealing with a small child. Instead of saying, ‘Now say it back to me, Billy,’ try saying, ‘I’m just double-checking that what I said made sense. I know I’m speaking in medical jargon, so I want to make sure you can tell me what you heard.'”
In addition, these athletes may not always seek your help, even when it’s needed. “When they’re sick or injured, learning-disordered kids are lousy reporters,” Lavoie says. “They over-react to minor things and under-react to major ones. They’ll walk around for weeks with a stress fracture and never mention it, and then get a splinter and want to go to the emergency room.”
For that reason, Lavoie advises maintaining extra vigilance and never assuming that no news is good news. “Don’t wait for them to come to you,” he says. “Check in with them regularly.”
INJURY & REHAB
While adjusting your communication strategies is key, it is also important to understand some of the extra struggles this population has managing injuries. When it comes to assessment, treatment, and rehab, there are some nuances in their responses and motivation that can be different than those you see with other athletes.
One distinction is the role anxiety can play when an athlete is injured. “For any athlete, being injured and in pain produces immediate anxiety, which makes it hard to process information,” Monroe says. “If you already have a processing problem, you’re really going to struggle to communicate when you’re injured.
“An athletic trainer dealing with an injured learning-disordered athlete can help simply by staying very calm,” he continues. “Statements like, ‘I know you must be feeling really anxious, and that’s natural,’ can also go a long way.”
Physical examinations require special care as well. “Some learning-disordered athletes are more sensitive to being touched than non-learning-disordered athletes,” Csillan says. “When I’m examining a learning-disordered athlete, I slow down. Before I touch them at all, I say, ‘I’m going to place my hands on your ankle. It’s not going to hurt. I just need to move it around a little bit.'”
When implementing a rehab plan, the first key is to understand that there are differences in how athletes in this population perceive time. “If you tell a learning-disordered athlete they are going to be kept off the field for 30 days, they may have very little sense for how long that is,” Lavoie says. “And if they’ve been rehabbing for 20 days and only have 10 left, they might have no idea they’re almost there. As far as they’re concerned, it could still be weeks away, and it’s hard to stay motivated when you don’t know where you’re at.”
One solution is to provide visual representations that allow athletes to track their rehab and see how far they’ve progressed. “Create a chart for the athlete listing their exercises and showing the days or weeks,” Lavoie says. “It’s very motivating because it shows them the light at the end of the tunnel.”
Chris Snoddy, ATC, Athletic Trainer at Goodpasture Christian High School in Madison, Tenn., has had success with this concept. “I make sure they have a chart to keep in their locker, and every day as they finish their rehab exercises, they check them off,” he says.
In extended rehab situations, short-term goals and rewards take on extra importance. “Telling a learning-disordered athlete, ‘Do all this work and you’ll be better in about three months’ doesn’t mean much to them,” says Csillan. “But setting a daily goal and giving a small reward does. I’ll tell the athlete, ‘If you get all the way through your program today, I have an ice pop in my freezer with your name on it.'”
“I also get the parents involved with this process,” Snoddy adds. “I give them the list of at-home exercises and together we come up with a reward system. The parents tell the athlete, ‘Every day that you finish your at-home rehab exercises, you can watch a television show, download a song on your iPod, or play a video game.'”
Lastly, the psychological ramifications of being injured and unable to play may carry a greater impact on those with a learning disorder. “Some learning-disordered athletes struggle with motor skills and are always on the fringes of making the team,” Szafnicki says. “When they’re injured, their first thought is, ‘That’s it–I’m done.’ And that can be devastating.
“Or maybe they’re a child who has a really hard time in the classroom but excels at their sport,” he continues. “In that case, it’s probably their lifeline to school, and being held out of practices and games can feel like the end of the world.”
Therefore, it’s even more important than usual to make sure you keep the athlete feeling connected to their team. “Stress to them that their job as an athlete on the team is to rehab–that they’re participating by getting healthy again,” Monroe says. “Tell the coach how well the athlete is doing in rehab, and make sure the athlete hears you say it.”
When Snoddy has an injured athlete with a learning disorder, he finds it helpful to pair the player with someone on the team who has overcome a similar injury. “I get them together and try to build a bond,” he says. “I look for caring, mature athletes to use as mentors. This approach is helpful with all injured athletes, but it especially helps the learning-disordered athlete.”
THE WHOLE ATHLETE
Making your athletic training room sensitive and accommodating to the needs of athletes with learning disorders is a huge first step in helping this population. A second step is being an advocate for these athletes in the sports world.
Csillan says he keeps an eye out for athletes with learning disorders at games and practices. “Many times I’ll see a coach yelling and I’ll see the athlete’s head go down, and I know we have a problem,” he says. “I go over and talk to the athlete and later we’ll talk to the coach together.”
Lavoie explains that two big red flags are sarcasm and yelling. “They often take everything literally, so they don’t understand sarcasm. And yelling just makes them shut down,” he says. “So if a coach uses these as part of his or her coaching style, the learning-disordered athlete is going to have real problems.”
These athletes sometimes also need a social mentor. “As a rule, learning-disordered kids don’t have as many close friends,” Lavoie says. “They don’t always understand the unspoken rules that govern social interaction, and as a result, they spend a lot of time alone. It can be very painful.”
To help them with social situations, Lavoie has pioneered a unique approach called “social autopsies.” With this system, a caring adult begins to pay attention to a learning-disordered child’s social interactions. When the child makes a gaffe, the adult engages in a postmortem of the event, taking it apart to see what went wrong.
“Athletic trainers are in a wonderful position to do this,” Lavoie says. “Let’s say you see the student-athlete breaking into a conversation between his teammates and changing the subject, resulting in the other athletes rebuffing him and telling him to leave them alone. This is the perfect time for a social autopsy. Gently take the athlete aside and say, ‘Let’s see what just happened there and what you could have done differently.’
“Then explain that people don’t like to be interrupted and rehearse with him some tactful ways to join a conversation,” he continues. “A social autopsy takes the child’s mistake and turns it into a learning opportunity. But it has to be done in an upbeat, supportive, and positive way.”
Finally, advocating for learning-disabled athletes means helping them achieve their goals. “Be careful that you don’t lower your expectations,” Monroe says. “Find out what their strengths are and push them to achieve just like you would any other athlete.”
And sometimes, the most important step is examining your own view of learning-disordered athletes. “If you had asked me about learning-disordered kids when I started out 20 years ago, I would have said, ‘They’re the worst. They’re not compliant, and I can’t stand to see them come in,'” Csillan says. “Then I had a son, and my son has ADHD. I watched what he went through, and it totally changed my perspective. I realized it was part of my job to get more creative in treating kids with learning problems.”
Csillan has since discovered that working with athletes who have learning problems is one of the most rewarding parts of his job. “I look at these special kids who come through my door very differently now,” he says. “I’ve learned that they can be the most motivated, helpful, engaged athletes I work with all year. In fact, they can be leaders. All they need is someone who cares and is willing to learn how to see the world the way they see it.”
Sidebar: DISCLOSURE DEBATE
Before you can help an athlete with a learning disorder, it’s obviously helpful to know that they have one, and what the individual’s diagnosis is. Due to privacy laws, this does not always happen.
“Different school districts have different ideas about what information an athletic trainer is entitled to,” says Chris Snoddy, ATC, Athletic Trainer at Goodpasture Christian High School in Madison, Tenn. “In my setting, each season I get a list of athletes who have medical conditions, and those with learning disabilities or ADHD are on that list. Next to their name, it tells me what their diagnosis is and whether they take any medications. If I need to know more, I can talk with the school nurse or school psychologist.”
South Allegheny High School in McKeesport, Pa., takes a different approach. “We don’t believe we have the legal right to identify these kids to an athletic trainer,” says Pat Monroe, MEd, CAGS, a school psychologist who serves as Director of Special Programs and Head Football Coach at the school. “If an athletic trainer has difficulty communicating with a student-athlete, they can come talk to me about the behaviors they’re seeing, but I believe it would violate the Family Educational Rights and Privacy Act [FERPA] to tell them about a child’s learning disorder unless I had consent from the parents.”
With few bright lines drawn in the disclosure debate, the decision is often left to lawyers who are likely to explain that the safest course of action is to limit access to the information. Although that may be the conservative approach, at least one expert in the field says it’s not the right approach.
“Disclosure is a huge issue in our field, and people interpret the laws differently,” says Rick Lavoie, MA, MEd, one of the nation’s leading advocates for children with learning disabilities. “But I believe an athletic trainer working for a public school is entitled to the information, and their ability to give quality care depends on their having it.”
If you don’t currently know which of your athletes have learning disorder diagnoses, there are steps you can take to find out. “I would initiate a conversation with school administrators about getting the information,” Snoddy says. “Discuss with them the reasons why it is important for you to know. It may be as simple as asking.”
Some sports medicine staffs ask parents directly, by adding a question about learning disorders to the pre-participation physical exam form. “The question should be very clear: ‘Does the child have a history of learning problems, or has he or she been diagnosed with a learning disability or ADHD?'” says Lavoie. “It would also be a good idea to clarify that the information will be kept confidential and only used by the athletic trainer to help him or her treat the child.”
Mark Szafnicki, MEd, Athletic Director at the Gow School, a school for boys with learning disabilities in South Wales, N.Y., believes most parents would be happy to provide the information. “I have a child with a learning disability myself, and I absolutely want everyone who is going to work with her to know,” he says. “Parents of learning-disordered children want to make sure their children are understood, and that means knowing about their diagnosis.”
I wanted to thank you for having the story “Lost in Learning” by Laura Ulrich in your December 2008 issue. I am a certfied athletic trainer and look forward to your magazine. This is the first time I have read any stories regarding learning disabilities and ADHD. I have currently treating an athlete with ADHD and a learning disability. I have been very frustrated until I read this article and found out how to approach her therapy and her as a human being and not just an athlete with an injury. Thank you so much for this awesome story and keep up the great magazaine. I always read it cover to cover!!!
Sarai Yates, ATC Rehab Unlimited Herrin Hospital