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THE ABC’s of Specific Learning Disorder                      .pdf version

by Ernest J. Bordini, Ph.D.
Clinical Psychology Associates of North Central Florida, P.A.   
CPANCF.COM   (352) 336-2888  Gainesville - Ocala
All RIghts Reserved

DSM-5 defines the term “Specific Learning Disorder” (commonly referred to as “LD” in the past) as "a neurodevelopmental disorder with a biological origin that is the basis for abnormalities at a cognitive level that are associated with the behavioral signs of the disorder".  This is the most recently used term for children who suffer significant difficulties an acquiring basic academic skills. This is the less technical term for what was previously termed as “Academic Skills Disorders” or dyslexia (defined in DSM-5 as one of the most common specific learning disorders and comprising of difficulties learning to map letters with the sounds of one's language - to read printed words), dyscalculia, dysgraphia, etc. The actual term for a particular learning disorder consists of the area of academic difficulty.  DSM-5 requires persisting learning keystone academic skills (Criteria A) with onset during years of formal schooling. 
rott puppy all rights reserved Ernest J. Bordini, Ph.D.
Key Academic Skills:
 
Reading of single words accurately and fluently
Reading comprehension
Written expression and spelling
Arithmetic calculation
Mathematical Reasoning
 
DSM-5 defines "persistence" in children and adolescents as "restricted progress in learning (i.e. no evidence the individual is catching up with classmates)."
 
DSM-5 further requires that the learning difficulties "manifest as a range of observable description behaviors or symptoms (Criterion A1-A6).  At least one symptom must persist for a period of 6 months despite interventions targeting the symptom.  A synopsis of the qualifying symptoms is presented below:
 
1.  Inaccurate or slow and effortful word reading, frequently guesses words, or has difficulties sounding out words.
2. Difficulty understanding what is read.
3. Difficulties with spelling.
4. Difficulties with written expression (such as multiple grammatical and punctuation errors, poor paragraph organization, written expression lacks clarity).
5. Difficulties mastering number sense, number facts or calculations.
6. Difficulties with mathematical reasoning.
 
A second key feature and requirement in DSM-5 Diagnosis of Specific Learning Disorder is that the individuals performance of the specific academic skill be "well below average for age" (Criterion B), but it goes on to state that average performance sustainable only through "extraordinarily high levels of support" may also be evidence of Specific Learning Disorder.  These deficits interfere with academic performance on measures such as grades and tests.  Avoidance of subject areas or school may be seen.  It is noted "However, this criteria also requires psychometric evidence from an individually administered, psychometrically sound, and culturally appropriate test of academic achievement that is norm-referenced or criterion-referenced".
 
While DSM-5 describes a necessity that skills be well below average, it notes academic skills lie on a continuum "so there is no natural cut-point that can be used to differentiate people with and without specific learning disorder".  A criterion of -1.5 S.D. below age norms or a Standard Score of 78 is identified as providing the greatest diagnostic certainty, but DSM-5 indicates clinical judgment may be used to identify specific learning disabilities in the range of -1.0 to -2.5 S.D. below the mean for age when there is other converging evidence from clinical assessment, academic history or school reports, or test scores.
 
The third criterion (Criterion C) specifies that the learning disabilities are "readily apparent" in the early grades, but at the same time notes that they may not appear until later grades in some individuals due to increased learning demands.
 
Specific Learning disabilities generally preclude academic deficits that are attributable to intellectual disabilities.; global developmental delay, hearing or vision disorders, or neurological or motor disorders.  DSM-5 notes specific learning disorders are diagnosed in individuals with "normal" levels of intellectual functioning defined ass approximately and IQ score of 70 +/- 5.  There is discussion of learning disability in "gifted" individuals, but no specific alternate criteria are described.
 
DSM-5 notes that if an intellectual, sensory, motor or neurological disorder is suspected, then assessment should include "methods appropriate for these disorders".
 
Classification Terms have changed, with Specific Learning Disorders being specified by the primary area of difficulty:
 
Specific Learning Disorder
 
315.00 with impairment in reading
315.2 with impairment in written expression  (includes problems with spelling accuracy)
315.1 with impairment in mathematics
 
Furthermore, disorders are specified by severity:
 
Mild:  Some difficulty in one or two academic domains, but mild enough that the individual may be able compensate or function well when provided appropriate accommodations or support services.
 
Moderate: "Marked" difficulties in one or more academic domains so that the individual is unlikely to become proficient without intervals of specialized and intensive teaching during the school years.  Some accommodations for at least part of the day may be needed at school, home or work to complete activities accurately and efficiently.
 
Severe: Severe difficulties in learning skills affecting several academic domains, so that the individual is unlikely to learn those skills without ongoing individualized and specialized teaching for most of the school years. Even with appropriate accommodations and/or services the individual may still not be able to complete activities efficiently.
 
Mathematics Disorder and Written Expression difficulties usually co-exist with Reading Disorders, but sometimes are diagnosed alone. DSM-5 estimates 5-15% of school age children will be diagnosed with a learning disorder.   Children who have early developmental difficulties with speech, such as not saying their first words by 12-14 months or two-word sentences by approximately two years may be prone to reading disorders. Children who suffer developmental coordination difficulties such as difficulties in eye-hand coordination or learning to walk may also be at increased risk for these disorders.

Children with disruptive behavior disorders such as Conduct Disorder, Oppositional Defiant Disorder or Attention-deficit Hyperactivity Disorder or may suffer from depressive disorders may also suffer from specific learning disorders. Perinatal injuries, medical disorders, lead poisoning, fetal alcohol syndrome, and chromosomal abnormalities have also been associated with learning disorders. The most common risk factor, however, is heredity.

Reading disorders, which may effect 4% of school children may be diagnosed as early as Kindergarten but often may not be diagnosed until formal reading instruction in first grade. Brighter children may not be diagnosed until demands increase in fourth grade or later.

Disorder of Written Expression is more difficult to estimate. Difficulty in writing, handwriting, difficulty remembering letter sequences of common words may appear as early as first grade but may not be diagnosed until writing demands increase towards the end of the year. It usually is identifiable by second grade.

Mathematics disorder is less frequent than reading disorders, effecting approximately 1% of school children. It is particularly important to rule out mathematics anxiety or attention difficulties since these can interfere with accuracy of calculation skills and cognitive flexibility. It often may not be diagnosed until 3rd or 4th grade, or sometimes later.
The impact of learning disorders on emotional adjustment and achievement has to be understood to appreciate the seriousness of these academic difficulties. Deficits in social skills and self-esteem are not uncommon, and nearly 40% of children with LD may drop out before graduating high school and may go on to have difficulties with employment.

Learning disorders are likely due to very subtle brain difficulties in processing visual and/or auditory material. While the difficulties may be subtle and require special testing by a licensed psychologist, school psychologist or sometimes a speech and language pathologist, these subtle difficulties can impact writing and reading speed, accuracy, and comprehension.

Children with reading difficulties may have difficulty in the phonological or “sounding out” aspects of reading. Children with combinations of both or multiple difficulties often exhibit the most severe reading difficulties.
 
Diagnosis is usually made by a licensed psychologist or school psychologists as the diagnosis is based on patterns of strengths and weaknesses in cognitive abilities and achievement.  This is accomplished by administration of standardized psychological tests such as the Wechsler or Woodcock-Johnson Tests.  These are administered individually to the student and are time consuming.  Unfortunately due to limited school resources, there is a trend to user briefer or short form tests, which tend to have a higher risk of mis-diagnosis.  In some cases more extensive neuropsychological testing may be necessary or helpful to identify underlying skills such as auditory or visual memory which may contribute to the disorder or co-existing conditions such as behavior problems, depression, coordination disorders or sensory-motor integration difficulties.
 
Educational testing may be performed throught the school psychological services department, though often waits are long and such evaluations tend to vary quite a bit accross counties in Florida and the country.  Educational testing is usually not covered by health insurance. 

The diagnosis of a learning disorder entitles the child to special services. Dr. Mel Levine, a developmental pediatrician, has stressed the importance of early help for learning disorders while establishing “islands of competence.” He recommended encouraging and developing the child’s natural strengths and interests to bolster self-esteem and reduce frustration when tackling new tasks.
 
The special education maze is often difficult to negotiate with various terms such as least restrictive alternative, response to intervention, IEP, accommodations, and others.  See Dr. Romero's article on this website: Special Education 101 - Terms and Definitions.

Once diagnosis is made an Individual Education Plan (IEP) is created for the child. The IEP is subject to approval by the parents. Special services are geared to provide a “free and appropriate education” in the “least restrictive” environment. Schools have a list of rights that parents and children have in relationship to this diagnosis and placement.

The common misconception that a child is simply “behind”, will “catch up” or “grow out of it” on their own is unfortunate because specialized remediation is often needed. Children who do master material may later encounter new difficult challenges as they encounter new academic demands and concepts. Adults with Learning Disorders often experience social and occupational difficulties.

Children may receive extra assistance and instruction by a learning specialist, speech and language therapy if necessary, use of a resource class, or in more severe cases full-time placement in a resource class. In later grades and college some of these children may qualify to have tests read to them, extra time for reading assignments, take oral instead of written exams, substitute class requirements, or may be able to utilize books on tape. Some colleges specialize in educating children with various learning disabilities. Locally, the University of Florida and Sante Fe Community College are experienced and helpful in assisting with guidance and necessary accommodations.

Since learning disorders are common and persistent problems, beware of false promises and magical cures. The axiom of “if it seems to good to be true, it probably is” applies to these treatments as well. Effective programs often involve intensive individual assessment, therapy, and individual and small group instruction. Area multi-disciplinary programs include the Ross-Mercer Clinic at the University of Florida and the Morris Developmental Center in Gainesville. Some children with milder reading difficulties find programs such as those offered through private learning centers helpful. Educators, family physicians, and pediatricians often can provide the names of psychologists or other providers who have expertise in providing evaluations and remediation.

REFERENCES:

American Psychiatric Association, Diagnostic and Statistical Manual of Mental Disorders - Fifth Edition. 2013
 
American Psychiatric Association, Diagnostic and Statistical Manual of Mental Disorders - Fourth Edition. 1994

Levine, Melvin Educational Care. A System for Understanding and Helping Children with Learning Problems at Home and in School Educators Publishing Service, Cambridge, Mass. 1994
 
FURTHER READING ABOUT SPECIFIC LEARNING DISABILITIES IN OUR ARTICLES AND ARCHIVES:
 
 
 
 
 
 Visit our other Websites for More on Learning Disabilities:
 
 
 

 
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