Understanding Specific Learning Disorder: A Comprehensive Guide

Specific Learning Disorder (SLD), also known as learning disorder or learning disability, is a neurodevelopmental condition that affects how individuals acquire, retain, organize, understand, and use information. Although it emerges during school-age years, it might not be acknowledged until adulthood. Affecting an estimated 5% to 15% of school-age children worldwide, early identification and support are crucial to promote academic success and mitigate associated emotional and behavioral challenges.

Defining Specific Learning Disorder

The term "Specific Learning Disorder" is a medical diagnosis, often used interchangeably with "learning disorder." "Learning disability," on the other hand, is a term employed in educational and legal contexts in Western countries. It's important to note that a learning disability, as defined in these systems, is not perfectly synonymous with the medical diagnosis of specific learning disorder.

The "Diagnostic and Statistical Manual of Mental Disorders," fifth edition (DSM-5), provides the diagnostic criteria for SLD. The DSM serves as a manual for physicians and other health professionals, offering clear descriptions of diagnostic categories to facilitate accurate diagnosis, communication, research, and treatment of individuals with specific disorders.

Historical Context and Evolution of Diagnostic Criteria

The need for clear diagnostic criteria began with the World Health Organization (WHO), which publishes "The International Classifications of Diseases" (ICD), a manual listing specific criteria for all medical illnesses, including mental disorders. This promotes uniformity of criteria worldwide, with member countries publishing their own diagnostic manuals based on the ICD, while maintaining the intent of the ICD diagnoses.

In the United States, the American Medical Association updates diagnostic criteria based on the revised ICD, and specialty organizations update criteria for their specific areas. The American Psychiatric Association (APA), in collaboration with other mental health organizations, updates the criteria for mental disorders, publishing them as "The Diagnostic and Statistical Manual of Mental Disorders" or DSM.

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The DSM first addressed learning problems in 1980 with the third edition (DSM-III), which also addressed motor and language difficulties. Specific Learning Disorders were defined as "Learning disorders interfering with the acquisition and use of one or more of the following academic skills: oral language, reading, written language, mathematics," affecting individuals with at least average abilities essential for thinking or reasoning.

The DSM, including the DSM-5, is a medical document for use by health and mental health professionals to assist them in making the correct clinical diagnosis and does not impact parents or educators directly, who continue to use IDEA (Individuals with Disabilities Education Act) and its revisions.

DSM-5 Criteria for Specific Learning Disorder

The DSM-5 considers SLD a neurodevelopmental disorder that impedes the ability to learn or use specific academic skills, such as reading, writing, or arithmetic, which are foundational for other academic learning. The learning difficulties are considered "unexpected" because other aspects of development appear typical. Early signs may appear in preschool years (e.g., difficulty learning letter names or counting objects), but a reliable diagnosis is typically made after formal education begins.

SLD is understood as a cross-cultural and chronic condition that typically persists into adulthood, with cultural differences and developmental changes in how the learning difficulties manifest. For example, children in English-speaking countries may struggle to learn the correspondence between letters and sounds to decode single words accurately, whereas adults may have mastered basic decoding skills but read slowly and with effort.

The DSM-5 diagnostic criteria for SLD reflect two major changes:

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One overarching category of SLD with 'specifiers': This characterizes the specific manifestations of learning difficulties at the time of assessment in three major academic domains: reading, writing, and mathematics (e.g., SLD with impairment in reading).
Elimination of the IQ-achievement discrepancy requirement: This has been replaced with four criteria (A - D), all of which must be met.

Criterion A: At least one of six symptoms of learning difficulties that have persisted for at least 6 months despite the provision of extra help or targeted instruction. These difficulties can manifest as:

Inaccurate or slow and effortful word reading (e.g., difficulty understanding the meaning of what is read).
Difficulties with reading comprehension.
Difficulties with spelling.
Difficulties with written expression.
Difficulties mastering number sense, number facts, or calculation.
Difficulties with mathematical reasoning.

Criterion B: The affected academic skills are substantially and quantifiably below those expected for the individual’s chronological age, causing significant interference with academic or occupational performance, or with activities of daily living, as confirmed by individually administered standardized achievement measures and comprehensive clinical assessment. Standardized scores below the 16th percentile might indicate SLD, and scores below the 7th percentile would be most consistent with SLD; however, clinicians are advised to use clinical judgment.

Criterion C: The learning difficulties begin during school-age years but may not become fully manifest until the demands for those affected academic skills exceed the individual’s limited capacities.

Criterion D: The learning difficulties are not better explained by developmental, neurological, sensory (vision or hearing), or motor disorders.

Impact of DSM-5 Changes on Clinical Practice

The changes in DSM-5 are likely to impact daily clinical practice, clinical research, the educational system, professional organizations and advocacy groups for LD, as well as individuals with LD, their families, and perceptions of LD in the community.

One substantial practice shift is necessitated by the change from subtypes of LD (Reading Disorder, Mathematics Disorder, Written Expression Disorder) to one overarching category. This change will require comprehensive assessment of academic skills and may reduce the challenges associated with defining the subtype of LD. Instead, specifiers may be used to more precisely characterize the range of problems present at the time of assessment.

The identification of a single overarching category of LD is consistent with many educational systems in which LD is delineated as an eligible category for special education, other services, and specific funding. This change may help reduce the confusion of parents and educators when ‘additional’ LDs are identified in later school years and help them better understand the developmental changes in the manifestation of SLD, which are in part triggered by the increasing learning demands of the curriculum.

However, this change may also require retraining of clinicians, school psychologists, and educators to identify and understand this conceptualization of LD and how to design learning pathways for each student with LD, who will have divergent and changing manifestations of their learning difficulties. Hopefully, this change might lead to better alignment of practice between clinical and educational communities.

The abandonment of the IQ-Achievement discrepancy criterion, as well as the omission of cognitive processing deficits in the diagnostic criteria, is another significant shift. Intellectual assessment will no longer be required for a DSM-5 diagnosis of SLD, except when Intellectual Disabilities are suspected. Similarly, there is no requirement for lengthy and costly neuropsychological assessment of cognitive processing skills for a diagnosis of SLD: such assessment might inform intervention plans but is not required for diagnosis. This means that psychologists may be able to shift from ‘assessment for diagnosis’ to ‘assessment for intervention’ and have more time to provide psychoeducation and consultation with parents and teachers.

For the education system, the elimination of the IQ-achievement discrepancy criterion might mean they are able to provide special education services to children with SLD and lower IQ (e.g., IQ score above 70 ± 5), but who do not have an Intellectual Disability.

The new criteria (particularly Criteria A and B) call for evidence of symptom persistence and the use of a wider array of data that may be used to confirm and quantify low academic achievement. By contrast to DSM-IV, psychometric data alone are insufficient for a DSM-5 diagnosis of SLD. A much closer collaboration is required between educators, clinicians, and parents, to provide access to formal and informal school records, academic portfolios, instructional history, as well as information from psychoeducational and clinical assessments. Closer and ongoing collaboration between clinicians, educators, parents, and the individual with SLD might lead to less confusion and frustration while navigating both worlds (educational, clinical) and better outcomes.

Types of Specific Learning Disorders

While the DSM-5 uses specifiers to indicate the areas of difficulty, several common terms are used to describe specific learning disorders:

Dyslexia

Dyslexia is a specific learning disorder that refers to a pattern of difficulties with accurate or fluent word recognition, decoding, and spelling. Individuals with dyslexia have difficulty connecting letters they see on a page with the sounds they make. Problems in reading begin even before learning to read. Kindergarten-age children may not be able to recognize and write letters as well as their peers. People with dyslexia may have difficulty with accuracy and spelling as well. Individuals with dyslexia may try to avoid activities that require reading whenever they can (e.g. - reading for pleasure, reading instructions).

Dysgraphia

Dysgraphia is a specific learning disorder used to describe difficulties with putting one’s thoughts on to paper. People with dysgraphia don’t just have “bad handwriting” - because of differences in their brains, they struggle to turn their thoughts into written language at the same level of complexity as their typically developing peers. There are five dysgraphia subtypes: dyslexic dysgraphia, motor dysgraphia, spatial dysgraphia, phonological dysgraphia, and lexical dysgraphia.

Dyscalculia

Dyscalculia is a specific learning disorder used to describe difficulties learning number-related concepts or using the symbols and functions to perform math calculations. Dyscalculia tends to become more apparent as children get older; however, symptoms can appear as early as preschool. Dyscalculia is thought to be present in 3%-6% of the general population, but estimates by country and sample vary. Many studies have found prevalence rates by gender to be equivalent.

Auditory Processing Disorder (APD)

If your child seems to frequently struggle to process what they hear, they may actually have an auditory processing disorder (APD). Children with this disability may mix up the order of sounds or struggle to distinguish between different sounds. Auditory processing disorder (APD), also known as central auditory processing disorder (CAPD), is often confused with or misdiagnosed as ADD, ADHD, or autism, but sometimes it turns out to be a co-occurring diagnosis, which is fairly common among children who have already been diagnosed with other disorders such as a speech delay or learning disability.

Language Processing Disorder (LPD)

A language processing disorder (LPD) is a type of learning disorder that affects a child’s ability to understand and use spoken language. Students with LPD may find it challenging to attach meaning to groups of sounds that form words or sentences. Unlike APD, in which there is difficulty identifying and retaining sounds after hearing them, in LPD, a child will struggle to process the language once they hear it, such as “attaching meaning to words, sentences and stories.”

Nonverbal Learning Disabilities (NVLD)

Children with a nonverbal learning disability often have trouble with organization, attention, executive functioning, nonverbal communication, and motor skills. Unlike the other learning disabilities which can be language-based, NVLD are about nonverbal skills, such as motor, visual-spatial, and social skills. Note that NVLD is not an official diagnosis and some experts may not recognize it. Symptoms can also overlap with other disabilities, such as autism or ADHD.

Visual Perceptual/Visual Motor Difficulties

These disabilities are not related to eyesight; rather, they impact how the brain processes what the eyes see. Some common areas of difficulty include spatial awareness, visual discrimination, visual memory, poor hand-eye coordination, whole/part relationships, and poor depth perception.

Assessment and Identification

There is no known etiology for LD. Although no current standardized screening tool for LD exists, primary care pediatricians should perform careful surveillance to determine if a child is at risk for LD. For instance, children with speech and language disorders, especially those with difficulties in phonics, are at increased risk for a future reading disorder and warrant close monitoring. When a child is in school, their primary care provider should monitor for academic difficulties.

Many school systems no longer use standardized testing as the first step in evaluating learning problems. Instead, a response to intervention (RTI) is often employed. In this model, a teacher identifies a child who is struggling in the classroom and provides them with supports that escalate as the child demonstrates the need. Interventions should be supported by evidence-based research.

Neuropsychological testing, including both cognitive testing and achievement testing, is utilized in the diagnosis of LD. Achievement tests can demonstrate if a child’s current abilities in specific academic areas are far below their chronological age and overall cognitive abilities.

In the Indian context, the NIMHANS Index for SLD is the most commonly used battery. It includes tests in two levels: Level I for the 5-7 years age group and Level II for 8-12 years.

Intervention and Support

School supportive services are critical for children with LD. Depending on the type and severity of their disability, interventions and technology may be used to help the individual learn strategies that will foster future success. Some interventions can be quite simple while others are intricate and complex. Teachers, parents, and schools can work together to create a tailored plan for intervention and accommodation to aid an individual in successfully becoming an independent learner. School psychologists and other qualified professionals often help design and manage such interventions.

Accommodations which facilitate the student to access the educational material. They include larger size pen/pencils, use of grippers, special papers which provide tactile feedback, use of spell checkers, audio books, and technological devices. The later may include voice recognition devices, touchpad devices, and calculators. Individualizing assessments in terms of time, length and allowance for breaks can be planned.

Modification is where the task and academic expectations from child are changed. Change in the delivery, content, or instructional level of subject matter or tests are implemented.

Remedial Education is being a process to help the child acquire age appropriate skillsin all his foundation areas which are required forattaining knowledge at his pace and potential. Interventions need to be systematic, well-structured and multi-sensory. They should include direct teaching, learning and time for consolidation. Repeated revision is to be factored in as attention is variable. It should be child centric, strategy taught for learning the content, focus on strengthening the basics Research hasshown to be effective, the intervention should be intensive 2-3 times a week and either at individual level or in a small group (1-2), using an explicit and systematic instruction in phonological awareness and decoding skills.

Depending on the type and severity of the problem, an individual educational plan is made for the child. The intervention planned is determined by the age/grade of child and the severity and type of deficits sand strengths. Usually it is 2-3 times a week for 3-4 years. In early years, developing language skills and basic skills of reading, writing and mathematics are the area of focus. In middle school besides basic skills, children need to learn concepts, critical thinking and problem solving. In secondary school accommodations and modifications to help the child to cope become more prominent. Whilst educational interventions are on the plan must also include components for the socio emotional development of child.

Assistive devices help children overcome obstacles and save time. Technological tools can vary from voice recognition programs (users dictate ideas and watch them appear on their computer screens) recording devices, word processors, concept mapping tools, smart pens and educational apps. There issoftware specially designed for children with SLD.(Grahphogame). Use of universal design allows easy access for children with SLD, whilst a child who has severe difficulties may use a computer to write, it would be helpful to encourage the child to try and write as brain activity is better with this.

Addressing Common Misconceptions

It is important to remember that learning disabilities are not the same thing as intellectual disabilities. Learning disabilities are considered specific neurological impairments rather than global intellectual or developmental disabilities. Often, learning disabilities are not recognized until a child reaches school age. One confounding aspect of learning disabilities is that they most often affect children with average to above-average intelligence. In other words, the disability is specific to a particular area and not a measure of overall intellectual ability.

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