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The Impact of Left Temporal LobeSeizure Disorder On Learning Disorders:A Case StudyDouglas M. Whiteside Ph.D. a , Jared R. Hellings a & JenniferBrown aa Argosy University, Seattle, WA, USAPublished online: 07 Jun 2010.

To cite this article: Douglas M. Whiteside Ph.D. , Jared R. Hellings & Jennifer Brown (2010) TheImpact of Left Temporal Lobe Seizure Disorder On Learning Disorders: A Case Study, The ClinicalNeuropsychologist, 24:6, 1026-1044, DOI: 10.1080/13854046.2010.486008

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The Clinical Neuropsychologist, 24: 1026–1044, 2010

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ISSN: 1385-4046 print/1744-4144 online

DOI: 10.1080/13854046.2010.486008

Grand Rounds

THE IMPACT OF LEFT TEMPORAL LOBE SEIZUREDISORDER ON LEARNING DISORDERS: A CASE STUDY

Douglas M. Whiteside, Jared R. Hellings, and Jennifer BrownArgosy University, Seattle, WA, USA

This case study describes the relationship between left temporal lobe epilepsy (TLE) and

learning disabilities in a 26-year-old male college student. The client developed seizures

following an episode of mycoplasma encephalitis at the age of 7. The client underwent a left

temporal lobectomy involving resection of the left mesial temporal lobe, amygdala,

hippocampus, and part of the brain stem 6 years prior to the current evaluation, in an

attempt to address the frequency of the seizures. The surgery was extensive, including

neocortical resection extending posterior to the vein of Labbe along the inferior temporal

gyrus. The lobectomy reportedly successfully eliminated the seizures and the need for

anti-seizure medications, but no neurological or neuropsychological follow-up occurred until

2009 when he was referred by his academic program for an evaluation of learning

disabilities. Results of the neuropsychological evaluation indicated significant expressive

language functioning deficits, with generally better-preserved receptive language. However,

compared to a pre-surgical neuropsychological evaluation there was evidence for subtle to

mild improvement in several aspects of cognitive functioning, likely due to seizure

elimination and discontinuation of the anti-seizure medication. Nonetheless, his deficits

resulted in significant functional impact on his academic abilities, thus implications for

academic intervention were discussed.

Keywords: Seizures; Learning disorders; Aphasia.

INTRODUCTION

Learning disorders are usually conceptualized as a neurodevelopmentaldisorders and not associated with a specific neurological event (Mapou, 2009).At times, however, patients with neurological conditions can have neuropsycholo-gical profiles closely resembling those with developmental learning disorders.Specifically, patients with a history of focal left temporal lobe damage may havecognitive and academic impairments similar to those with developmental spoken orwritten language disorders because neurodevelopmental learning disorders are oftenassociated with deficits in cognitive abilities like language (Mapou, 2009), which arealso common in left temporal lobe seizures disorders (Buchtel & Selwa, 2009; Loring

The Clinical Neuropsychologist, 24: 1026–1044, 2010

http://www.psypress.com/tcn

ISSN: 1385-4046 print/1744-4144 online

DOI: 10.1080/13854046.2010.486008

Grand Rounds

THE IMPACT OF LEFT TEMPORAL LOBE SEIZUREDISORDER ON LEARNING DISORDERS: A CASE STUDY

Douglas M. Whiteside, Jared R. Hellings, and Jennifer BrownArgosy University, Seattle, WA, USA

This case study describes the relationship between left temporal lobe epilepsy (TLE) and

learning disabilities in a 26-year-old male college student. The client developed seizures

following an episode of mycoplasma encephalitis at the age of 7. The client underwent a left

temporal lobectomy involving resection of the left mesial temporal lobe, amygdala,

hippocampus, and part of the brain stem 6 years prior to the current evaluation, in an

attempt to address the frequency of the seizures. The surgery was extensive, including

neocortical resection extending posterior to the vein of Labbe along the inferior temporal

gyrus. The lobectomy reportedly successfully eliminated the seizures and the need for

anti-seizure medications, but no neurological or neuropsychological follow-up occurred until

2009 when he was referred by his academic program for an evaluation of learning

disabilities. Results of the neuropsychological evaluation indicated significant expressive

language functioning deficits, with generally better-preserved receptive language. However,

compared to a pre-surgical neuropsychological evaluation there was evidence for subtle to

mild improvement in several aspects of cognitive functioning, likely due to seizure

elimination and discontinuation of the anti-seizure medication. Nonetheless, his deficits

resulted in significant functional impact on his academic abilities, thus implications for

academic intervention were discussed.

Keywords: Seizures; Learning disorders; Aphasia.

INTRODUCTION

Learning disorders are usually conceptualized as a neurodevelopmentaldisorders and not associated with a specific neurological event (Mapou, 2009).At times, however, patients with neurological conditions can have neuropsycholo-gical profiles closely resembling those with developmental learning disorders.Specifically, patients with a history of focal left temporal lobe damage may havecognitive and academic impairments similar to those with developmental spoken orwritten language disorders because neurodevelopmental learning disorders are oftenassociated with deficits in cognitive abilities like language (Mapou, 2009), which arealso common in left temporal lobe seizures disorders (Buchtel & Selwa, 2009; Loring

Address correspondence to: Douglas M. Whiteside, Ph.D., Argosy University, 2601-A

Elliott Avenue, Seattle, Washington 98105, USA. E-mail: dwhiteside@argosy.edu

Accepted for publication: April 12, 2010. First published online: June 7, 2010

� 2010 Psychology Press, an imprint of the Taylor & Francis group, an Informa business

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& Meador, 2001). Here we describe a male college student status post surgery forintractable temporal lobe seizures, which began following an episode ofmycoplasma encephalitis at age 7. His clinical presentation was quite similar tocollege students with developmental language disorders who seek out academicaccommodations, but the etiology was quite different. Before describing the case, wesummarize the relevant research literature on seizure disorders and the relationshipto impairment of spoken and written language.

Seizures can result from a variety of illnesses, disorders, substance use andwithdrawal, or fever that result in hyperexcitability in neuronal pathways (Lezak,Howieson, & Loring, 2004). A number of different types of seizures have beenidentified in the literature, including complex partial seizures, which have beenassociated with focal regions of the brain and involve altered mental status (Lezaket al., 2004). Complex partial seizures have been most associated with onset in thetemporal lobes and create numerous psychological, social, and neuropsychologicalproblems (Buchtel & Selwa, 2009). For example, Buchtel and Selwa noted the riskof depression and suicide was greatly increased in patients with all types of seizuresand the loss of the ability to drive was an often-cited complaint. Seizure disorders,or epilepsy, also significantly impact the development of academic skills(Butterbaugh et al., 2004) and ultimately employment (Buchtel & Selwa, 2009)through a combination of the effects of an underlying neurological disorder orlesion, the seizures themselves, emotional reactions to the disorder, the anti-seizuremedications, surgeries, and/or coincidence (Beghi, Cornaggia, & Elia, 2001).Nevertheless, the specific roles of each of these factors were not well understood(Beghi et al., 2001).

Research has associated specific neuropsychological deficits with the localiza-tion of seizures (Buchtel & Selwa, 2009). In particular, specific learning difficulties,such as reading comprehension disorders, were associated with left hemisphereseizure focus compared to right hemisphere seizure focus (Butterbaugh et al., 2004;Hermann, Wyler, & Somes, 1991). Research has also provided evidence thatchildren and adults with seizure disorders have a higher incidence of comorbidlearning disabilities than the general population (Beghi et al., 2001; Beghi,Cornaggia, Frigeni, & Beghi, 2006; Williams, 2003). For example, Breier et al.(2000) investigated the relationship between temporal lobe epilepsy (TLE) andlearning disabilities in adults. Participants were grouped based on average or below-average IQ and reading deficient or not-reading deficient. Of the 92 consecutivepatients in their study, 46% were identified as having academic deficits consistentwith a reading disability. This was much higher than estimates of all learningdisorders in the general population, which ranged from 2% to 10% (APA, 2000).Moreover, these academic deficits were not related to global intellectual functioningdeficits.

The relationship between learning disabilities and localization of seizures wasinvestigated in 31 epilepsy patients with left hemisphere language dominance byButterbaugh et al. (2004). Patients with left TLE were compared to patients withright TLE on measures of reading comprehension, written language, andmathematical calculations. Learning disabilities were defined as approximately1 standard deviation below the mean on measures of academic functioning. Thisdefinition was more consistent with current research and federal laws than the

TEMPORAL LOBE SEIZURES AND LEARNING DISORDERS 1027

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traditional IQ/achievement discrepancy definition (Fletcher, Morris, & Lyon, 2003).

Results indicated that the left TLE group had significantly higher rates of learning

disabilities than the right TLE group. In fact, almost 74% of the left TLE group had

a learning disability compared with just 8% of the right TLE group. The most

common learning disabilities in both groups were in reading and written language,

consistent with Breier et al.’s findings (2000). Results also provided evidence of the

significant comorbidity of TLE and learning disabilities.Although there was evidence of the comorbidity of learning disorders and

epilepsy (Breier et al., 2000; Butterbaugh et al., 2004; Chaix et al., 2006), Ferrari

(2007) noted that the literature has been difficult to interpret. Specifically, the

definitions of learning disabilities and measures of academic functioning have been

widely disparate. The IQ/achievement discrepancy model has been shown to have

little research evidence in general (Fletcher et al., 2003). However, it may have even

less utility in those with epilepsy, given that medications and the seizures themselves

may result in an underestimation of actual intellectual functioning (Butterbaugh

et al., 2004). Therefore it may be particularly important for clinicians evaluating

clients with a history of seizures to be aware of the limitations of the discrepancy

model, as well as the evidence of the significant comorbidity of these syndromes.

Other models of the assessment of deficits associated with learning disorders

integrate in more extensive neuropsychological data about underlying cognitive

deficits in learning disorders (Mapou, 2009) and were likely more appropriate to

seizure disorders populations with learning disorders. The neuropsychological

approach to learning disorders proposed by Mapou was utilized with this

individual.Since a pre-surgical neuropsychological evaluation was available, it was

possible to differentiate the impact of the TLE from the effects of the lobectomy

to treat this disorder. This was an important and intriguing aspect of this case,

since previous literature has indicated that individuals undergoing surgery can

experience either declines or improvement in language, memory, and other

cognitive functions depending on a number of factors (Helmstaedter &

Kockelmann, 2006; Loring & Meador, 2001). Specifically, surgical interventions

for seizure disorders can result in improvement in functioning due to the removal

of the pathogenic influence of the seizures themselves (Cornaggia & Gobbi, 2001;

Loring & Meador, 2001). Other factors associated with improved functioning

included younger age, being seizure-free after surgery, classic mesial temporal lobe

epilepsy (as opposed to atypical temporal lobe epilepsy), and less hippocampal

atrophy (Loring & Meador, 2001; Seidenberg, Herman, Wyler, Davies, Dohan, &

Leveroni, 1998). Loring, Meador, and Lee (1994) also found evidence that when

acute language-based impairments occurred after surgery, these deficits often

improved significantly over time.Although research supports a link between left temporal lobe epilepsy and

verbal learning disorders (Chaix et al., 2006), no specific case descriptions could be

found. Thus this case report was written to address this weakness in the literature

and provided a prototypical example of an individual presenting initially with a

learning disorder in reading who also had a well-established history of TLE and

subsequent left temporal lobectomy.

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CASE DESCRIPTION

The patient, CK, was a 26-year-old, Caucasian, right-handed man with a long-

term history of complex partial seizures reportedly secondary to mycoplasma

encephalitis at age 7, and s/p left temporal lobectomy (LTL) and hippocampal-

amygdala resection in 2003. He was referred for a neuropsychological evaluation to

assess his cognitive functioning secondary to being placed on academic probation by

his college. The evaluation was requested specifically to address learning disabilities

that might be impacting his academic functioning.There was no evidence of difficulties with the pregnancy and his

infancy/toddler years were also unremarkable. Early developmental history was

reported to be unremarkable and within expected limits. Developmental milestones

in speech/language and fine/gross motor skills were also within age-appropriate

limits. There was also no reported difficulty academically or behaviorally in school

settings prior to the onset of the encephalitis. CK lived in various states in the

Midwest and west coast prior to settling permanently in the Pacific Northwest at

age 8. He was the middle of five siblings.In this particular case, the onset of the seizure disorder followed an episode of

mycoplasma encephalitis. Mycoplasma encephalitis has been described as the most

common central nervous system complication in children with mycoplasma

pneumoniae bacteria infections (Koskiniemi, 1993). Studies have shown that

approximately 5–10% of all encephalitis cases were caused by these bacteria, and

that 20–60% of children with mycoplasma pneumoniae develop some type of

neurological complication (Bitnun, Ford-Jones, Blaser, & Richardson, 2003).

Another study (Daxboeck, Blackly, Seidl, Krause, & Assadian, 2004) provided

evidence that neuroradiologically detected cerebral abnormalities occurred in

approximately 30% of participants.CK was reportedly in good health until age 7, when his parents discovered him

non-responsive with a blue tinge to his skin. Medical records noted he was conscious

but was unresponsive to verbal interactions for 3 days, and medical evaluation

eventually resulted in the diagnosis of mycoplasma encephalitis. The records

indicated that after this time his mental status quickly improved and he was

discharged after 1 week. Shortly after his discharge he developed complications,

primarily medication refractory partial complex seizures consisting of stereotyped

movements including right arm outstretching, picking at his clothes, and lip

smacking. Records stated that he was initially treated with Dilantin after an

electroencephalogram (EEG) indicated left temporal lobe spikes. Once on Dilantin

he became moody and emotionally labile. Over the next several years he experienced

repeated left cerebral hemisphere focus complex-partial seizures with the same

stereotyped movements. In an attempt to control the seizures, over the years several

different medication trials were conducted, although with each medication he

continued to have breakthrough seizures. After numerous minimally successful

medication trials, it was determined that a combination of Lamictal and Tegretol

resulted in the best seizure control, although he continued to experience the seizures

over the next 14 years. Missed dosages frequently resulted in an exacerbation of the

seizures.

TEMPORAL LOBE SEIZURES AND LEARNING DISORDERS 1029

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In addition to the seizures CK also experienced emotional problems, includingsevere mood swings. It was observed that his social interaction significantlydecreased after the encephalitis as well. He confirmed that he was socially isolated

and had extensive difficulty making friends. Compounding this problem, his parentsremoved him from school and homeschooled him because he began to demonstrate

significant academic achievement problems after the encephalitis and onset of theseizures. He reported that, although the social isolation continued throughout his

development, the mood swings did not continue to be a significant problem once

medication intervention for the seizure disorder was implemented, even thoughbreakthrough seizures continued to be an issue. Because he was homeschooled and

did not receive evaluations through the school district, CK was uncertain about anyacademic difficulties during these years. He eventually received a Graduate

Equivalency Degree (GED) but could not remember the date he obtained hisdegree.

Beginning in 2000, when CK was age 17, he was evaluated for possible surgical

resection of the seizure focus, given the medication refractory nature of the seizures.At that time he underwent a neuropsychological evaluation at the treating facility,

as well as CT scans and further EEGs. The EEGs continued to demonstrate lefttemporal lobe spikes. At the same time CT scans were conducted at the treating

hospital. These scans were requested with the patient’s written permission. The

treating hospital digitized these analogue images, including the markings made bythe radiologists at the time, and can be seen in Figure 1. The lesion noted in the

records can be observed in the mesial temporal lobe on these images. CT scanreports and medical records did not characterize the lesion except to note its

location in the mesial left temporal lobe and that it was likely a post-infectiousabnormality.

Figure 1 Digitized head CT scan taken in 2000. The scan was printed on film, and then digitized by the

treating hospital per the patient’s request. Note the radiologist’s markings, which circled the lesion in the

mesial temporal lobe.

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As part of the pre-surgical work-up, CK participated in a neuropsychologicalevaluation at that time in 2000. Complete raw data from this pre-surgicalneuropsychological evaluation could not be obtained, in spite of several attempts.However, the written report included sporadic scores on assessment instrumentsthat, when available, are presented alongside the current neuropsychological data inTables 1–9. The pre-surgical neuropsychological evaluation report concluded thatCK had significant deficits in written spelling, confrontation naming, word finding,and verbal memory. Milder deficits in speed of information processing were alsoreported, while general intellectual functioning and visual spatial functioning werewithin the average range. Unfortunately, since only a few summary scores of themeasures (e.g., WMS-III, see Table 4, Rey Complex Figure, see Table 5) wereprovided, it was not possible to definitively verify the reported conclusions. Per theclient’s report, this was the only neuropsychological or cognitive/academicevaluation for the patient prior to the current one.

Table 1. Measures of intellectual functioning and effort

Data from 2000 Data from 2009

TOMM Raw score

Trial 1 50

Trial 2 50

Trial 3 50

Standard score

WTAR 89

WAIS-III Standard score Standard score

Full Scale 91

Verbal IQ 85

Performance IQ 102

Verbal comprehension 86 84

Perceptual reasoning 93 114

Working memory 82 94

Processing speed 79 84

WAIS-III Scaled score Scaled score

Similarities 9

Vocabulary 6 6

Information 6 6

Comprehension 7

Block design 11

Picture arrangement 10

Matrix reasoning 10 13

Picture completion 13

Letter-number seq. 10

Digit span 8

Arithmetic 9

Symbol search 9

Coding 5

TOMM¼Test of Memory Malingering; WTAR¼Wechsler Test of Adult Reading;

WAIS-III¼Wechsler Adult Intelligence Scale – III.

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After completing this evaluation CK decided not to pursue the surgical optionat that time, and continued to be treated medically for the seizures, although thesuccess of the medications was limited in that he continued to experiencebreakthrough seizures. Further medical records indicated that video EEGmonitoring conducted in 2002 was consistent with previous EEGs in terms of aleft temporal lobe focus. During the monitoring he was weaned from hismedications and quickly experienced three separate episodes of partial complexseizures that began with a ‘‘funny feeling’’ followed 10–12 seconds later bystereotyped motor movements including right arm and leg posturing, right headdeviation, and generalized jerking. At this time, CK stated he decided to pursue thesurgical option.

Table 2. Measures of achievement

Data from 2000 Data from 2009

WIAT-II Standard score

Reading 82

Mathematics 93

Written language 66

Oral language 77

Word reading 86

Reading comprehension 67

Pseudoword decoding 97

Numerical operations 95

Math reasoning 92

Spelling 56

Written expression 76

Listening comprehension 76

Oral expression 79

WIAT-II Quartile

Reading speed 1st

WRAT-3 Standard score

Word recognition 93

Spelling 59

Arithmetic 88

WIAT–II: Wechsler Individual Achievement Test-II; WRAT-3:Wide Range

Achievement Test-3.

Table 3. Measures of language

Data from 2000 Data from 2009

Raw Standard score Raw Standard score

Boston naming 34 24 38 24

Token test 163 90th*

FAS 18 28 29 38

Animals 13 24

*¼percentile score.

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Thus in 2003, when CK was 21 years old, he underwent a left temporallobectomy and amygdala hippocampal resection in an attempt to address thefrequency of the seizures. Medical records reported that the surgery was quiteextensive, including neocortical resection extending posterior to the vein of Labbealong the inferior temporal gyrus. The surgery also involved an extensive amygdalahippocampectomy with extension back to the brain stem. Further details of the

Table 4. Memory measures

Standard score

WMS-III

Auditory immediate (68*) 80

Visual immediate 91

immediate memory 82

Auditory delayed (76*) 92

Visual delayed 100

Auditory recognition delayed 100

General memory 95

Working memory 88

WMS-III Raw Scaled score

Logical memory I 24 5

Logical memory II 11 6

Faces I 40 11

Faces II 43 13

Verbal paired associates I 13 8

Verbal paired associates II 7 11

Family pictures I 34 6

Family pictures II 38 7

Auditory recognition delayed 50 10

CVLT-II Raw z-score

Trial 1 5 1

Trial 5 11 �0.5

Trial B 1 �3

Trial 1–5 total 36 T¼ 34

Short delay free recall 9 �0.5

Short delay cued recall 8 �1.5

Long delay free recall 8 �1.5

Long delay cued recall 5 �1.5

Recognition 14 �1

False positives 3 0.5

Data from 2000 Data from 2009

Raw Raw T score

RCFT immediate recall 30 23 48

RCFT delayed recall 28 25 52

RCFT recognition 23 60

*¼Data from 2000; WMS-III¼Wechsler Memory Scale – III; CVLT-II¼California Verbal Learning

Test –II; RCFT¼Rey Complex Figure Test.

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procedure were not available because the operative report and hospital records fromthe time were not available. Post-surgical pathology reports indicated that the leftanterior and posterior-inferior temporal lobe tissue showed subpial, intracortical,and white matter astrocytosis, while the left amygdala tissue sample showed mildastrocytosis and the left hippocampal tissue showed sclerosis, Watson grade III, andgranular cell dispersion. The pathology report indicated no evidence of neoplasm.According to the medical records and CK’s self-report, this complex surgery waseffective in addressing the seizures because he has not had one since that time.

After his recovery from surgery CK did not follow medical advice forcontinued monitoring and instead moved to the Southwest. He was lost to medicalfollow-up for several years while he began post-secondary training in art with thegoal of pursuing a career in animation. He then transferred to a different program inthe Pacific Northwest to be closer to family, where he was in a Bachelor of Fine Arts

Table 7. Measures of motor functioning

Data from 2000 Data From 2009

Raw T score Raw T score

Finger tapping DOM 50 41 50.8 40

Finger tapping NON 44 40 46.2 43

Grip strength DOM 47 41

Grip strength NON 45 46

Grooved pegboard DOM 74 38

Grooved pegboard NON 88 33

DOM¼Dominant; NON¼Non-dominant.

Table 5. Measures of visual spatial abilities

Data from 2000 Data from 2009

Raw Percentile Raw T score Percentile

RCFT Copy 35 416th 36 416th

Benton Judgment of Line Orientation 23 40th 29 86th

Benton Facial Recognition 47 50

Hooper Visual Organization Test 26.5 52

RCFT¼Rey Complex Figure Test.

Table 6. Measures of attention and concentration – data from 2009 only

Raw Standard score

BTA 15 Percentile 25–74th

Spatial span 12 SS¼ 6

Letter–number sequencing 11 SS¼ 10

Trails A 39 seconds T¼ 29

BTA¼Brief Test of Attention; Trails A¼Trail-making Test; Spatial Span from Wechsler Memory

Test – III; Letter–Number Sequencing from WAIS-III.

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program majoring in animation at the time of the current evaluation. He reportedthat he had no health insurance and so had not had any medical orneuropsychological follow-up since the surgery in 2003.

School records from his current program indicated failing grades in all courseswith strong language components (e.g., English Composition) but his grades in artcourses were generally As and Bs, which was consistent with his self-report.Specifically, CK stated that spelling, single word reading, reading comprehension,and any activities that required extensive memorization were extremely difficult.CK also described ongoing problems with social anxiety and feelings of isolationfrom his peers due to his academic problems, although he denied symptoms of amajor depressive or anxiety disorder since the surgery. He stated that he was behindin reading and writing skills compared to age-matched peers. He reportedlyperformed well in mathematics and in tactile/kinesthetic learning.

NEUROPSYCHOLOGICAL ASSESSMENT RESULTS

Because of these academic problems, CK was referred for a neuropsycholo-gical evaluation to assess for possible learning disorders and to make recommenda-tions for academic accommodations. CK participated in a comprehensiveneuropsychological evaluation that included a variety of procedures, including

Table 8. Measures of executive functioning

Data from 2000 Data from 2009

Raw Raw Standard score Percentile

WCST # Trials 70

WCST total correct 61 117

WCST total errors 10 9 117

WCST preservative responses 5 6 126

WCST preservative errors 5 129

WCST non-preservative errors 6 4 113

WCST # categories completed 6 416th

WCST trials to 1st category 2 416th

WCST loss of set 416th

Booklet category test 34 T¼ 43

Trails B 65 T¼ 41

WCST¼Wisconsin Card Sorting Test; Trails B¼Trail-making Test.

Table 9. Measures of emotional functioning – elevated PAI scales and subscales

T score

SCZ 72

SCZ – T 75

STR 73

BOR – N 72

PAI¼Personality Assessment Inventory; SCZ¼Schizophrenia; SCZ – T¼Thought

Disorder; STR¼Stress; BOR – N¼Negative Relationships.

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a clinical interview, review of available medical records, and the followingstandardized assessment instruments: Wechsler Adult Intelligence Scale-III(WAIS-III, The Psychological Corporation, 1997), Wechsler IndividualAchievement Test-II (WIAT-II, The Psychological Corporation, 2002), TrailMaking Test (Reitan & Wolfson, 1985), Wechsler Memory Scale-III (WMS-III,The Psychological Corporation, 1997), California Verbal Learning Test-II(CVLT-II, Delis, Kramer, Kaplan, & Ober, 2000), Rey Complex Figure Test(RCFT, Meyer & Meyer, 1995), Benton Judgment of Line Orientation(JLO, Benton, Sivan, Hamsher, Varney, & Spreen 1994), Benton FacialRecognition Test (Benton et al., 1994), Trailmaking Test (Reitan, 1992),Controlled Oral Word Association Test (COWAT, Strauss, Sherman, & Spreen,2006, FAS and Animal fluency), Boston Naming Test (BNT, Kaplan, Goodglass, &Weintraub, 1983), Token Test (Strauss et al., 2006), Finger Tapping Test (Reitan &Wolfson, 1985), Grip Strength Test (Reitan & Wolfson, 1985), Booklet Category(BCT, DeFillippis & McCampbell, 1997), Test of Memory Malingering (TOMM,Tombaugh, 1996), Wisconsin Card Sorting Test (WCST, Heaton, Chelune, &Talley, 1993), Personality Assessment Inventory (PAI, Morey, 1991), and the BeckDepression Inventory-II (BDI-II, Beck, Steer, & Brown, 1996). Either standardnorms from the test manuals or norms published by Heaton, Miller, Taylor, andGrant (2004) were used for the analysis of the data, and are presented in Tables 1–9.

CK arrived to all of his appointments on time and presented with goodhygiene and appropriate dress. He was cooperative and stated that he was eager tocomplete the assessment process. His voice was quiet, and there were noticeablepauses before answering. He would occasionally become distracted when speakingand exhibited a tendency to answer questions in a slow and somewhat incompletemanner. When asked to elaborate, he appeared to have difficulty finding the wordsto complete his thought and would instead talk around his point, at times neverfully completing his thought. His affect tended to be quite restricted, and heverbalized mild anxiety during the initial assessment session about the process. Healso occasionally verbalized frustration with his performance, but there was noevidence of any change in non-verbal behaviors or vocal inflection to accompanythese statements. In spite of the behavioral observations, he consistently deniedcognitive or affective symptoms of a major depressive episode. Formal assessmentof effort utilizing the TOMM was within expected limits. Embedded measures ofeffort, such as forced choice recognition on the CVLT-II, were also within expectedlimits. There was no evidence that symptom validity assessment was completed inthe 2000 evaluation.

During the current evaluation, measures of his intellectual functioningindicated that verbally mediated intellectual functioning was in the low averagerange while his visually mediated intellectual functioning was in the average range(see Table 1). Compared to the 2000 evaluation, his Verbal Comprehension Indexwasunchanged, but his Perceptual Organization Index score was significantly higher(POI in 2000¼ 93, POI in 2009¼ 114). This 21-point scaled score increase wasunlikely due to practice effects, given the extensive time between evaluations and thelarge increase. Additionally, Working Memory was significantly higher during thecurrent evaluation, while Processing Speed continued to be the most problematic forhim on this measure and was not significantly different. Particularly concerning,

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Vocabulary and Information subtests both continued to be in the borderline impairedrange, while verbal abstract reasoning (Similarities) were in the low average toborderline range. His visual reasoning and problem-solving abilities were signifi-cantly stronger, in the high average range. A psychometric measure of estimatedpremorbid intellectual functioning was also administered (Wechsler Test of AdultReading,WTAR, The Psychological Corporation, 2001) but it was evident that, sincethis measure utilized reading single words to estimate premorbid functioning, his lowaverage range performance was most likely related to his academic and languageprocessing issues and not a valid estimate of functioning.

Performance on measures of academic achievement indicated that CK was inthe average range of functioning in mathematical ability, but performed in theextremely low range on reading comprehension, reading speed, and spelling(see Table 2). Based on comparisons with the 2000 evaluation, which utilized theWide Range Achievement Test-3rd edition (WRAT-3), there was some evidence forimprovement in his academic achievement in mathematics relative to the normativesample at this time. However, his reading ability was essentially unchanged, at leastin terms of single word reading ability. The 2000 evaluation did not directly assessreading comprehension, which was actually his most serious reading problem. Thissuggested more difficulty with processing verbally based stimuli that were morecomplex (e.g., sentences versus single words). Written spelling also had notimproved in the 9-year period between the evaluations, and written expression wasalso quite far below the normative population. Measures of Oral Expression andListening Comprehension were also quite limited.

Based on the previous neuropsychological evaluation and his medical history,it was hypothesized that language functioning would be the most impaired domain,and the neuropsychological assessment results generally confirmed this hypothesis.In particular, measures of expressive language functioning were the mostproblematic for him, consistent with the previous evaluation (see Table 3).Receptive language functioning, assessed formally with the Token Test and subtestsof the WIAT-II, and informally through observation, indicated that he wasgenerally able to follow most straightforward commands and directions, butcomprehension of more complex language was poorer. In terms of expressivelanguage functioning, results indicated a severe deficit in word retrieval, particularlyconfrontation naming. He had extensive difficulty with naming even with phonemiccues on the BNT. Likewise, semantically (Animal Fluency) and phonetically(FAS words) based verbal fluency were in the mildly impaired range on theCOWAT, with animal fluency poorer than FAS, which was consistent with theBNT and suggested particular difficulty with the verbal retrieval of nouns. Hisexpressive language deficits manifested on other verbally based tasks, such as on theWAIS-III. Specifically, while Vocabulary, Information, and Comprehensionsubtests from the WAIS-III were not direct measures of language processing,deficits in this domain typically adversely impact performance on these tasks. InCK’s case the challenges on these WAIS-III measures provided converging evidencewith more specific language measures. Interestingly, specifically, Similarities wasnot as problematic, most likely due to the nature of the required responses.Similarities typically required less verbal production than Vocabulary andComprehension. These expressive language deficits were also noticeable

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functionally, in that throughout the evaluation he had significant difficulty with

word finding in conversation.Interestingly, while the evaluation results demonstrated significant word

retrieval difficulties consistent with his left TLE and LTL, the results also indicated

a slight improvement in his functioning compared to the previous evaluation

(for example, BNT raw score improved from 33 to 38, and there was improvement on

COWATmeasures). Once again, given the very long time-frame between evaluations,

practice effects were thought unlikely to account for this improvement. More likely,

the improvement was related to the abatement of the seizures and the fact that CK

was no longer taking anti-seizure medications.The results of formal memory assessment were consistent with mild deficits in

verbal memory. While CK’s hippocampal resection could have affected his memory

functioning, there was evidence of at least some improvement in verbal memory

functioning after the surgery where the hippocampus was resected (see Table 4).

Specifically, in the 2000 evaluation, the WMS-III Auditory Immediate Index was 68

and the Auditory Delayed Index was 76, but his current evaluation results indicated

higher Index scores of 80 and 92, respectively. This improvement provided evidence

against a significant adverse impact of the hippocampal resection per se on verbal

memory. However, since there could have been hippocampal dysfunction related to

his seizure disorder and encephalitis, the results implied that his memory

functioning was not further compromised by the resection of the hippocampus.Additionally, his expressive language functioning difficulties were hypothe-

sized to be contributing to his poor performance on verbal memory. For example,

Logical Memory I was a scaled score of 5, but Verbal Paired Associates I was a

scaled score of 8, indicating that he tended to perform better on verbal tasks that

required relatively less verbal production. This pattern was also noted above

with the differential performance in Comprehension/Vocabulary subtests and

Similarities. In each case his performance was better when the verbal production

required for success on the task was less. Thus, the leading hypothesis was that his

performance on verbal encoding tasks was related to the complexity of the verbal

output.There was also evidence that CK could partially compensate for this verbal

learning difficulty with repetition of verbal information. For example, his verbal

memory performance improved with more repetition of the information. This was

also observed on the CVLT-II where his learning curve was quite poor for the first

three trials (5, 5, 6 words recalled respectively), but the fourth and fifth trials

demonstrated remarkable improvement (9, 11 words recalled respectively).Measures of visual-spatial functioning were generally within the average

range, consistent with his medical history (see Table 5). For example, CK performed

above average on visual reasoning and visual construction tasks, such as Matrix

Reasoning, Block Design, and the RCFT Copy Trial. Compared to his significant

language difficulties, his visual-spatial strength stood out noticeably. The results

also indicated that his encoding of visual information was stronger than his verbal

memory functioning, at least partially due to the fact that his responses did not

require verbal expression. For example, immediate and delayed recall of the RCFT

was within the average range (see Table 5).

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Motor-free visual spatial tasks, such as JLO and Benton Facial Recognition,were in the average range. On measures of attention (Table 6), motor functioning(Table 7), and executive functioning (Table 8), he performed generally in theaverage range, although there was some variability in his performance on theattentional tasks on the WMS-III and WAIS-III. WCST and the BCT were bothwithin the average range, and there was no evidence of perseverative tendencies. Hisperformance on the WCST was stronger in general than on the BCT, even thoughboth were within the average range. This slightly poorer BCT compared to WCSTperformance suggested the possibility of greater difficulty with rule learning anddeductive reasoning abilities for him (Perrine, 1993), although it was difficult tomake firm conclusions since performance on both tasks was in the average range.Despite his processing speed deficits, Trailmaking B actually had a T score withinthe average range as well. Thus it was determined there was no evidence for deficitsin cognitive flexibility, concept formation, or set shifting ability. In terms of motortesting there was no evidence of lateralized deficits in either grip strength or grossmotor speed.

Formal personality assessment was also completed, utilizing the PAI and abrief screening measure for depression, the BDI-II (see Table 9). The PAI waschosen because it was a well-validated measure of personality and emotionalfunctioning, and was commonly administered by this clinic in learning disabilityevaluations due to the fact that the PAI’s reading level was low and the phrasing ofthe items was relatively straightforward (Morey, 1996). The validity scales were allwithin the average range, indicating CK likely responded in a valid andinterpretable manner. The only clinical scale with an elevation was the SCZ scale,and the only subscale elevated with the SCZ-T (Thought disorder), which was notunexpected given his presenting complaints of difficulty with communication andconcentration, and the fact that elevations on SCZ-T are not uncommon inindividuals with a history of including seizure disorders (Morey, 1996; Pizzi,Chapin, Tesar, & Busch, 2009). He also responded similarly to individuals whoexperienced considerable negative relationships and psychosocial stressors, but hedid not endorse problems with serious emotional distress. He did endorse milddepressive symptoms on the BDI-II. The BDI-II could be somewhat confounded byphysical symptoms related to his medical condition, since he denied cognitive andaffective symptoms of depression in interview and on the PAI. Item analysis on theBDI-II indicated that he preferentially endorsed physiological items, such asdecreased appetite, decreased libido, and decreased sleep over more cognitive oraffective items.

The results of the evaluation were most consistent with diagnoses of ReadingDisorder and Disorder of Written Expression, utilizing DSM-IV-TR criteria (APA,2000). Review of the history was consistent with acquired rather than congenitallearning disorders. Arguably other diagnoses could also be appropriate in this case,including Expressive Language Disorder or Cognitive Disorder NOS secondaryto TLE and LTL. Given the context of the evaluation and the referral questions,utilizing learning disorder diagnoses was felt to be the most appropriate way toanswer the referral question and provide access to accommodations. The likelyneurological etiology and acquired nature of the learning disorders was emphasizedin the written report. This was considered the most appropriate way to address the

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diagnosis since there was evidence from the evaluation that his neurological historycontributed to the learning disorder symptoms.

A diagnosis related to emotional functioning issues was also considered. WhileCK did not meet specific DSM-IV-TR criteria for a major depressive disorder oranxiety disorder, he acknowledged significant frustrations, emotional distress, andanxiety secondary to his current academic and social difficulties. Thus it wasdetermined that a diagnosis of an Adjustment Disorder with Mixed Anxiety andDepressed Mood was more appropriate, given the evidence.

DISCUSSION

This case was a description of a 26-year-old Caucasian male referred fora learning disability assessment because of academic difficulties who had a historyof medication refractory complex partial seizures beginning at age 7 following anepisode of mycoplasma encephalitis. He underwent a left temporal lobectomy in2003, but had essentially no medical or neuropsychological follow-up untilpresenting for this evaluation. Based on his self-report, medical services wereoffered to him following the lobectomy, but he initially chose not to access thembecause he felt that he was ‘‘cured’’ of his seizures and did not need further follow-up. It was not until he was in his post-secondary academic program that verballybased academic problems emerged as a significant issue.

CK’s case illustrates an excellent example between left cerebral hemispheredysfunction, in particular localized left temporal lobe dysfunction, and verballearning disabilities, an association that has been consistently demonstrated in theresearch literature (Beghi et al., 2006; Hermann et al., 1991; Williamson, 2003).Given the nature of his seizure disorder and the LTL, it was remarkable that he wasnot more cognitively and linguistically impaired, based on what might be expectedgiven this research literature. This should not distract from the evidence for seriouslanguage-based learning disabilities, but his resilience was noteworthy in thisrespect. Unfortunately, in spite of this there was also considerable evidence forongoing, serious learning disabilities in reading and written expression that, as apractical matter, were interfering with his role functioning as a student.

Related to this point, another fascinating aspect of CK’s case was that, whilehe continued to experience significant language processing deficits, there actuallyhad been some improvement in these abilities in spite of very significant surgery tothe left temporal lobe. Most likely this modest improvement was due to the fact thathe no longer experienced complex partial seizures, and no longer took anti-seizuremedication, both of which have been shown to adversely impact cognitivefunctioning in seizure disorder patients (Buchtel & Selwa, 2009; Loring &Meador, 2001). The fact that he had a rather typical mesial temporal lobe seizuredisorder was another factor that predicted a better outcome (Seidenberg et al.,1998). In fact there was evidence for generalized improvement in cognitivefunctioning, not just language functioning. For example, his POI increased by 21points, far more than would be expected from any practice effects alone, especiallywith a 9-year test–retest interval.

The third important implication of this case related to the issue of diagnosinglearning disabilities themselves, particularly in the context of a known neurological

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condition with known neurobehavioral sequelae. Sources appeared to differ on thisissue. For example, the DSM-IV-TR (APA, 2000) stated that LD could bediagnosed in the presence of other medical or neurological conditions (which shouldbe coded on Axis III), while Mapou (2009) offered a definition of LD whereneurological conditions must be ruled out, which would exclude acquired learningdisorders from a neurological injury. In the current case it was decided that since thereferral question specifically involved learning disorders, and the evaluation resultsdemonstrated the relationship between LD symptoms and his seizure disorder, itwas appropriate to provide the acquired LD diagnosis and explain the relationshipto the seizures and the surgical intervention. In this particular case, the referralsource was a college program that required a DSM-IV-TR LD diagnosis(if appropriate) to provide accommodations, although in other contexts anInternational Statistical Classification of Diseases (ICD-9) code, such as AcquiredDyslexia, could be used. Thus this case illustrated a particular circumstance whendiagnosing a LD in a patient with an underlying neurological condition wasindicated and appropriate because the LD diagnosis was explicit in the referralquestion if the data supported it.

Another aspect of the evaluation involved the insight into his psychologicalfunctioning. Specifically, his affect was flat and he tended to respond in a slow,relatively monotone manner, considerably out of proportion to his reportedsubjective feelings but not to the point of being dysprosodic. This presentationresulted in the assumption by several faculty members in his program that he wasabusing controlled substances, although there was no evidence of ongoing substanceuse. Instead the current evaluation provided the insight that his affectivepresentation was related to the resection of his amygdala and hippocampus, whilethe slow verbal responding was secondary to his language-processing difficulties.There was evidence from his history of significant emotional and behavioralproblems starting after the encephalitis and seizure disorder, which abated after thesurgery in 2003. After this surgery his subjective feelings of emotional distressimproved, even though his affective presentation continued to be quite constricted.This timing of the disconnection between subjective experience and emotionalexpression increases the likelihood that the surgical intervention, specifically thelimbic system resection, was the etiology for these issues.

Based on the assessment results, it was determined that CK was unlikely toexperience further significant improvement in his functioning, but that reasonableacademic accommodations and specific interventions likely would be beneficial tohim in compensating for his deficits. First an intervention with his faculty wasimplemented to increase their understanding of his behavioral and emotional issues.The faculty were given education about underlying cause of his affectivepresentation and slow speech. The faculty responded positively to the interventionand continued to work with the patient on his classroom demeanor.

Second, it was felt that further speech-language therapy would also bebeneficial to address compensatory strategies for the language-processing andcognitive deficits. Since there is a greater risk for word-finding difficulties withnouns as opposed to verbs (Glosser & Donofrio, 2001), particular languagerehabilitation strategies focused on word finding with nouns was recommended(Thompson & Johnson, 2010).

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Third, a referral for individual tutoring was made, although there wereconcerns about the effectiveness of this intervention given the neurologicalunderpinnings of his deficits. Nonetheless, specific reading interventions for thetutor focusing on reading fluency and reading comprehension could be beneficial.Development of multi-modal learning strategies and examination procedures werealso recommended, given his remarkable strengths in visual spatial abilities. Theexplicit strategy was to assist him in developing compensatory strategies for thelanguage-based deficits.

In addition to these recommendations, several recommendations foraccommodations were made to his academic program. The recommendationswere based on the literature and applicable state and federal laws addressingreasonable accommodations (e.g. Americans with Disabilities Act; Fletcher, Lyons,Fuchs, & Barnes, 2007; Peterson & Pennington, 2010). These accommodationsincluded providing flexible deadlines and extra time on tasks and tests, which wasrecommended to help compensate for the decreased reading fluency andcomprehension, word retrieval, and expressive writing issues. Other accommoda-tions included writing with the aid of a computer (spell check and grammar check),and recording classroom lectures for playback later. Finally, psychotherapy wasrecommended to assist him in coping with the stressors of his medical and academicsituation. Specific suggestions for working with a psychotherapist experienced inneurological conditions who could integrate less-verbal modalities in psychother-apy, such as art or music therapy, were made.

He has continued in his college program with these accommodations in place.Based on continued consultation with his academic program, he was expected tograduate successfully, and has not failed any other classes even though his gradescontinued to be poorer in courses with strong language production expectations.The consultation with the administration of his academic program also indicatedthat the perceptions of his behaviors were successfully modified, which was alsohelpful in his progress.

The current case illustrates the importance of a neuropsychological approachto learning disability assessment. While not all cases have as clear an etiology to theLD as this patient, the ultimate value of the assessment for the patient both inunderstanding how the seizures and surgery impacted his language academicfunctioning and affective presentation, and in helping him compensate for theseissues. It was the hope that these interventions would increase the likelihood thatCK could successfully complete his program.

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