Chapter 5. Specific Learning Disorder

Abstract

According to DSM-5 (American Psychiatric Association 2013), specific learning disorder (LD) comprises a heterogeneous group of disorders charac-terized by persistent difficulties with learning academic skills in a variety of domains, including reading, spelling, written expression, and mathematics (Box 5-). The symptoms of specific LD must have persisted for at least 6 months, even though interventions that target those difficulties were provided. Furthermore, the affected academic skills must be substantially and quantifiably below levels expected for the person?s age and cause interference with academic or occupational performance or with activities of daily living (based on a clinical synthesis of the individual?s history, school reports, and psychoeducational assessment). The learning difficulties are not accounted for by intellectual disabilities, by uncorrected problems with visual or auditory acuity, or by lack of language proficiency, inadequate educational instruction, or psychosocial adversity. The academic domains and subskills that are impaired are specified within each of the following domains: reading (word reading accuracy, reading rate or fluency, reading comprehension), written expression (spelling accuracy, grammar and punctuation accuracy, clarity or organization of written expression), and mathematics (number sense, memorization of arithmetic facts, calculation fluency or accuracy, accurate math reasoning). Finally, the severity of the LD is identified.Although comorbidity across types of LD is notably high, treatments typically target the particular features of each specific type of LD. Nevertheless, a literature review indicates that there are guiding principles for treatment that apply to all areas of LD. In this chapter, we begin with a discussion of these general guidelines, then describe treatments for the different kinds of impairment in LD, and finally discuss the implications of disorders often comorbid with LD. Although most academic interventions take place within the school system or through programming available through specialists, this chapter focuses on what has been shown to work and what characteristics specific to LD can be effectively targeted for intervention.DSM-5 Diagnostic Criteria for Specific Learning DisorderDifficulties learning and using academic skills, as indicated by the presence of at least one of the following symptoms that have persisted for at least 6 months, despite the provision of interventions that target those difficulties:Inaccurate or slow and effortful word reading (e.g., reads single words aloud incorrectly or slowly and hesitantly, frequently guesses words, has difficulty sounding out words).Difficulty understanding the meaning of what is read (e.g., may read text accurately but not understand the sequence, relationships, inferences, or deeper meanings of what is read).Difficulties with spelling (e.g., may add, omit, or substitute vowels or consonants).Difficulties with written expression (e.g., makes multiple grammatical or punctuation errors within sentences; employs poor paragraph organization; written expression of ideas lacks clarity).Difficulties mastering number sense, number facts, or calculation (e.g., has poor understanding of numbers, their magnitude, and relationships; counts on fingers to add single-digit numbers instead of recalling the math fact as peers do; gets lost in the midst of arithmetic computation and may switch procedures).Difficulties with mathematical reasoning (e.g., has severe difficulty applying mathematical concepts, facts, or procedures to solve quantitative problems).The affected academic skills are substantially and quantifiably below those expected for the individual?s chronological age, and cause 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. For individuals age 17 years and older, a documented history of impairing learning difficulties may be substituted for the standardized assessment.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 (e.g., as in timed tests, reading or writing lengthy complex reports for a tight deadline, excessively heavy academic loads).The learning difficulties are not better accounted for by intellectual disabilities, uncorrected visual or auditory acuity, other mental or neurological disorders, psychosocial adversity, lack of proficiency in the language of academic instruction, or inadequate educational instruction.Note: The four diagnostic criteria are to be met based on a clinical synthesis of the individual?s history (developmental, medical, family, educational), school reports, and psychoeducational assessment.Coding note: Specify all academic domains and subskills that are impaired. When more than one domain is impaired, each one should be coded individually according to the following specifiers.Specify if:315.00F81.0With impairment in reading:Word reading accuracyReading rate or fluencyReading comprehensionNote:Dyslexia is an alternative term used to refer to a pattern of learning difficulties characterized by problems with accurate or fluent word recognition, poor decoding, and poor spelling abilities. If dyslexia is used to specify this particular pattern of difficulties, it is important also to specify any additional difficulties that are present, such as difficulties with reading comprehension or math reasoning.315.2F81.81 With impairment in written expression:Spelling accuracyGrammar and punctuation accuracyClarity or organization of written expression315.1F81.2With impairment in mathematics:Number senseMemorization of arithmetic factsAccurate or fluent calculationAccurate math reasoningNote:Dyscalculia is an alternative term used to refer to a pattern of difficulties characterized by problems processing numerical information, learning arithmetic facts, and performing accurate or fluent calculations. If dyscalculia is used to specify this particular pattern of mathematic difficulties, it is important also to specify any additional difficulties that are present, such as difficulties with math reasoning or word reasoning accuracy.Specify current severity:Mild: Some difficulties learning skills in one or two academic domains, but of mild enough severity that the individual may be able to compensate or function well when provided with appropriate accommodations or support services, especially during the school years.Moderate: Marked difficulties learning skills in one or more academic domains, so that the individual is unlikely to become proficient without some intervals of intensive and specialized teaching during the school years. Some accommodations or supportive services at least part of the day at school, in the workplace, or at home may be needed to complete activities accurately and efficiently.Severe: Severe difficulties learning skills, affecting several academic domains, so that the individual is unlikely to learn those skills without ongoing intensive individualized and specialized teaching for most of the school years. Even with an array of appropriate accommodations or services at home, at school, or in the workplace, the individual may not be able to complete all activities efficiently.