Specific Learning Disorder

Overview 

Specific Learning Disorder is considered to be a neurodevelopmental disorder that hinders academic skill-learning and development. On the basis of symptomatology and the academic domain implicated by the manifestation of the disorder, Specific Learning Disorder may be diagnosed as one or more of the following: 

• Dyslexia: impairment in reading ability
• Dysgraphia: impairment in written expression 
• Dyscalculia: impairment in mathematical ability 

Specific Learning Disorder can have significant functional consequences, observable primarily in the form of high levels of psychological distress, low academic performance, high rates of school dropout, low likelihood of attaining higher-level education, unemployment, and low income. 

There is generally a male predominance in the prevalence of Specific Learning Disorder, and diagnosis occurs after the commencement of formal education. An interaction of biological and environmental factors and the consequent cognitive factors resulting from the same are implicated in the etiology of the disorder. There are frequent comorbidities, including neurodevelopmental conditions and mood disorders. 

The management of Specific Learning Disorder is informed greatly by the manifestation of symptoms and their severity, and usually takes the form of psychoeducation, learning intervention, and psychotherapy. 

Signs and Symptoms 

Signs and symptoms of Specific Learning Disorders may include: 

Difficulties in obtaining key academic skills including: 

1. Reading single words with accuracy and fluency
2. Comprehension skills
3. Expressing oneself through writing
4. Adequate spelling 
5. Arithmetic calculation
6. Mathematical reasoning
7. Language delays or deficits 
8. Lack of interest in playing games that include language sounds such as repetition or rhyming
9. Experiencing difficulties learning nursery rhymes
10. Mispronouncing words and using baby talk
11. Trouble remembering names, days of the week, alphabets, and numbers
12. Trouble connecting letters to sounds
13. Being slow in reading out loud
14. Difficulty sequencing letters and numbers
15. Consistently underperforming in academics 
16. Avoiding activities that require academic skills
17. Delays in attention, language, or motor skills

Risk Factors

Specific Learning Disorders are generally more prevalent among males than females, though some differences have been observed among subtypes. While a higher proportion of males experience difficulties in spelling and reading, a higher proportion of females have been shown to face impairments in terms of arithmetic abilities.

The symptoms of the disorder typically become recognizable when children begin formal schooling and are expected to engage in learning involving reading, writing, spelling, and mathematics. However, certain precursors such as delay in language and difficulties with fine motor skills may be observed prior to this.

Specific Learning Disorders are the result of cognitive impairments that arise out of biological causal factors, including the interaction of genetic and environmental factors. There is a significantly high risk of Specific Learning Disorder for individuals with a family history of the disorder, and familial risk is always considered as a predicting factor involved with the disorder.

A relatively higher genetic risk of dyslexia (reading difficulties) or dyscalculia (mathematic difficulties) exist within Specific Learning Disorders. The occurrence of dyslexia among parents, as well as parental literacy skills are considered to be a significant predictor of the disorder. 

Variances in brain activation have also been identified between individuals with Specific Learning Disorder and control groups. In understanding dysgraphia (writing difficulties), problems in utilizing the orthographic loop are often implicated, which may also have genetic causation.

The orthographic loop refers to the process of storing written words in the mind, and then reproducing them through sequential motor output of the hand upon receiving feedback from the eye. 

Various cognitive deficits are implicated in the occurrence of Specific Learning Disorders. Commonly, these include domains of processing speed, memory, and well as temporal processing. It is interesting to note that within these cognitive deficits, certain clusters have been found to be more significantly associated with certain subtypes than others.

For instance, dyslexia is associated more largely with slow verbal processing and poor verbal memory. Dyscalculia, on the other hand, is more significantly associated with factors such as temporal processing, and limitations in verbal and visuo-spatial memory. 

Perinatal factors are largely considered in understanding the etiology of Specific Learning Disorders. Pre-term birth has been associated as a predictor for dyscalculia. However, the influence of genetic etiological factors is considered to be fairly more significant as compared to the implications of environmental factors in the context of Specific Learning Disorder. 

Neurodevelopmental disorders are common comorbidities associated with Specific Learning Disorder, such as ADHD, developmental coordination disorder, and Autism Spectrum Disorder. Other mental disorders, such as anxiety disorders, depressive disorders, and bipolar disorders may also occur concomitantly. 

Diagnosis

Specific Learning Disorder is typically diagnosed after the commencement of formal education, as an integral aspect of diagnosis is the objective lack of academic skills and abilities. 

On the basis of specific lacks in skills and the academic domains implicated, Specific Learning Disorder may be diagnosed as one or more of the following: 

• Dyslexia
  The diagnosis of dyslexia is made when the presentation of Specific Learning Disorder produces difficulties in accurately recognizing and reading words, being unable to decode and read words with fluency, facing problems with comprehension while reading, as well as having poor spelling abilities. Dyslexia is one of the most common manifestations of Specific Learning Disorder.
  
• Dysgraphia
  Impairments in writing, manifested as spelling errors, as well as incorrect grammar and punctuation use, are diagnosed as Dysgraphia. The presentation of Specific Learning Disorder in this subtype is also accompanied by a lack of clarity and organization while expressing oneself through written means.
  
• Dyscalculia
  Patterns of difficulties in processing numeric information and learning arithmetic facts is considered to inform the diagnosis of Dyscalculia. Individuals with this presentation of Specific Learning Disorder face significant problems in performing calculations and carrying out mathematical reasoning.
  

A thorough clinical evaluation is often undertaken while initiating the diagnostic process for Specific Learning Disorder. A comprehensive case history can help the clinician determine the likelihood of the disorder on the basis of predictors such as familial risk and developmental delays.

On the basis of the presentation of the disorder, various forms of testing may be carried out. In terms of dyslexia, diagnostic procedures may work on assessing speed, accuracy, and comprehension while reading.

In the case of dysgraphia, indications such as decreased writing speed and discrepancy between verbal IQ and spelling achievement may be looked out for, and evaluations of posture, pencil grip, tremors, and observed writing habits may be made.

For dyscalculia, difficulties in basic arithmetic observation, fact retrieval, and word problems may be observed. Various standardized tests are typically administered for all types of Specific Learning Disorder. 

The DSM-5 provide the following diagnostic criteria for the diagnosis of Specific Learning Disorder: 

Difficulties 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:

1. 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).
2. 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).
3. Difficulties with spelling (e.g., may add, omit, or substitute vowels or consonants).
4. Difficulties with written expression (e.g., makes multiple grammatical or punctuation errors within sentences; employs poor paragraph organization; written expression of ideas lacks clarity).
5. 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).
6. Difficulties with mathematical reasoning (e.g., has severe difficulty applying mathematical concepts, facts, or procedures to solve quantitative problems).
7. 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.
8. 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).
9. 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 psycho-educational assessment.

Other than specifying the subtype of Specific Learning Disorder on the basis of the affected academic domain, specifications are also made on the basis of severity.

Treatment

Psychosocial and diagnosis-specific interventions are the mainstay of management when it comes to Specific Learning Disorder. It is vital for those with diagnosed with the disorder to receive individualized support on the basis of their specific symptomatic difficulties.

It is vital for schools to incorporate these interventions and specifications into the education system in order to accommodate students with learning difficulties. Certain modifications, accommodation, and remediation that align with the needs of the students must be made. On the basis of the policies in place, most children with learning difficulties are eligible to avail of special education services. 

Psychoeducation is an integral part of management, and involves explaining the implications of the disorder and the future needs of the individual. Adequate sensitivity training may be imparted onto teachers in order to better equip them to facilitate the students’ integration into classroom settings and the overall education system.

Certain responsibilities may also fall upon the parents, such as working on supporting the child through practice sessions at home. 

Management of dyslexia typically calls for reading and spelling support, and intervention strategies are generally informed by the individual status of the child on the basis of symptoms they are experiencing and the severity of the same.

Creating and sustaining family environments that encourage reading and facilitate the process may be instrumental for the development of skills. In terms of spelling, support focusing on phonics and trends in spelling can be effective. 

For dysgraphia, again, intervention is largely dependent on the impairments in various writing processes and the level of severity at which the individual experiences them. At the primary schooling level, children may be engaged in interventions focusing on motor activities and orthographic tasks.

Making the use of various materials and activities can help stimulate the child’s writing skills. These may include tracing, drawing lines within mazes, playing with clay, finger-tapping, practicing adequate posture, and reinforcing proper grip. 

Management strategies for dyscalculia mainly incorporate domains such as basic numerical skills, arithmetic skill development, procedural knowledge, and the process of making factual knowledge more automatic by helping individuals adequately understand and recall formulae.

The various mathematical skills may be reinforced through frequent practice, consolidation of solving strategies, breaking sums into more basic components, and encouraging strategic learning. Administering interventions in small and interactive groups has shown efficacy. 

It is also important to take into consideration the possible comorbidities, such as ADHD, that may confound intervention. Therapy for concomitant mood disorders can be helpful to alleviate any psychological distress that may arise as a result of the functional consequences of learning difficulties. 

Specialist 

Symptoms of Specific Learning Disorder may be observed in educational settings, and can be pointed out by school counsellors with adequate expertise. Educational psychologists, special education teachers, and occupational or physical therapists may be involved in the diagnosis of the disorder. On the basis of the intervention recommended, professionals with significant training and experience may facilitate management of the disorder.