Does my child have a learning disability?

In honor of Learning Disability Awareness Month, this blog focuses on what a learning disability is and how to find out if your child has one.

Areas of concern

Many variables make parents and teachers start to wonder if a child has a learning disability, but often, these variables overlap with many possible scenarios (e.g., attention problems, immaturity). It is important to gather as much information as possible and involve trained personnel to determine why your child is struggling. Some of the most common areas of concern raised during referrals include but are not limited to:

Poor academic performance in one or all subjects
Memory problems
Processing concerns
Lack of progress academically
Not meeting age and/or grade level standards (e.g., curriculum, state testing, etc.)
Poor handwriting
Work avoidance
Not remembering what was read
Struggling to recall math facts

What is a learning disability?

In order to determine if a child, or adult, has a learning disability, it is important to understand what a learning disability is. The definitions vary depending on the criteria utilized.

DSM-5

The Diagnostic and Statistical Manual of Mental Disorders, 5th Edition (DSM-5) is the diagnostic manual published by the American Psychiatric Association in 2013. The DSM-5 is typically utilized by a range of healthcare professionals from licensed physicians to psychologists predominantly within the US.

DSM-5 Diagnostic Criteria

The DSM-5 uses the term Specific Learning Disorder. In order to make this diagnosis, there should be a combination of observation, interviews, review of history, and school reports. Neuropsychological and psycho-educational testing may also assist with identification of interventions. The diagnostic criteria are summarized below:

Persistent difficulties in at least one of the following areas:
- Reading (e.g., fluency, comprehension)
- Math (e.g., reasoning, calculation, facts, number sense)
- Writing (e.g., spelling, grammar, punctuation, organization)
Academic skills significantly below expected level, which causes problems in school
Difficulties begin during school age
Learning difficulties are not better explained by intellectual disability, vision or hearing problems, a neurological condition, adverse conditions (e.g., homelessness), lack of instruction, or difficulties speaking or understanding the language

DSM-5 severity scale

It is important to note there are variations in severity outlined in the DSM-5.

Mild: Some difficulties with learning in one to two academic areas but may be able to compensate.
Moderate: Significant difficulties with learning, requiring some specialized instruction and accommodations or supportive services.
Severe: Severe difficulties with learning, affecting multiple academic areas and requiring ongoing intensive specialized teaching.

DSM-5 specifiers

As a result of the diagnostic criteria, there are specifiers of Specific Learning Disorder outlined below:

Specific Learning Disorder with impairment in reading includes possible deficits in:
- Word reading accuracy
- Reading rate or fluency
- Reading comprehension
Specific Learning Disorder with impairment in written expression includes possible deficits in:
- Spelling accuracy
- Grammar and punctuation accuracy
- Clarity or organization of written expression
Specific Learning Disorder with impairment in mathematics includes possible deficits in:
- Number sense
- Memorization of arithmetic facts
- Accurate or fluent calculation
- Accurate math reasoning

DSM-5 changes from DSM-IV-TR

Prior to the DSM-5 being release in 2013, the Diagnostic and Statistical Manual of Mental Disorders, Fourth Edition, Text Revision (DSM-IV-TR) was in effect. The DSM-5 criteria involve one broad category where the separate types of learning disability described in the DSM-IV-TR are considered to be encompassed. In other words, rather than requiring deficits to be linked to reading, writing, and/or math, the DSM-5 criteria describe general academic difficulties while also providing the specifiers listed above for reading, writing, and math. There are many articles discussing whether or not this was a controversial decision.

Controversy

Some people argue the changes to the DSM-5 are problematic because Dyslexia, Dyscalculia, and Dysgraphia are not identified as diagnostic categories. These disabilities were not identified specifically due to significant differences in their definitions. Furthermore, dyslexia is an alternative term in the DSM-5 for problems with accurate or fluent word recognition, poor decoding, and poor spelling abilities. Dyscalculia is listed as an alternative term for a pattern of trouble with processing numerical information, acquiring knowledge of math facts, and completing calculations with fluency and accuracy. Dysgraphia is not mentioned by name at all.

ICD-11

The International Classification of Diseases, Eleventh Revision, Clinical Modification (ICD-11) is an international classification system used by healthcare providers. It was developed by the World Health Organization (WHO). The DSM-5 was developed solely for mental conditions, while the ICD-11 pertains to all medical conditions. Originally there were significant differences between the DSM and ICD but these have decreased over time. However, there are many who feel it is confusing to have two diagnostic systems. ICD codes are often submitted as part of insurance claims. Therefore, if your child receives a psychological evaluation, you may see both DSM-5 and ICD-11 codes reported.

ICD-11 diagnostic criteria

The ICD-11 uses the term “Developmental Learning Disorder.” It is characterized by:

Significant and persistent difficulties in academic skills (e.g., reading, writing, math)
Academic performance is significantly below what would be expected for age and intellectual ability
These difficulties significantly impact academic or occupational functioning
Must manifest originally during early school years
Not better explained by an intellectual disability, hearing or vision, neurological or motor disorder, lack of educational opportunity, lack of understanding of instructional language, or psychosocial adversity

ICD-11 subtypes

The ICD-11 subtypes are:

With impairment in reading
With impairment in written expression
With impairment in mathematics
With other specified impairment of learning

IDEIA (Special Education)

Special Education requirements are based on the federal law, Individuals with Disabilities Education Improvement Act (IDEIA) which was the 2004 reauthorization of the Individuals with Disabilities Education Act (IDEA). It is important to note that public schools must comply with federal and state level laws about Special Education eligibility. Therefore, it is recommended you look into your state requirements as well to be fully informed.

IDEIA definition

IDEIA defines a Specific Learning Disability (SLD) as follows:

A disorder in one or more of the basic psychological processes involved in understanding or in using language, spoken or written, that may manifest itself in the imperfect ability to listen, think, speak, read, write, spell, or do mathematical calculations, including conditions such as perceptual disabilities, brain injury, minimal brain dysfunction, dyslexia, and developmental aphasia.
SLD does not include learning problems that are primarily the result of visual, hearing, or motor disabilities, of intellectual disability, of emotional disturbance, or of environmental, cultural, or economic disadvantage.
A group of qualified professionals including the parent holds a meeting (ARD in Texas, IEP elsewhere) to review all data (e.g., evaluation, educational need) and determine whether or not a student qualifies with an SLD. They can make this determination if:
- The child does not perform adequately for their age or meet state-approved grade-level standards (TEKS in Texas) in one or more of the following areas, when provided with learning experiences and instruction (i.e., adequate instruction, interventions, access to school/education) appropriate for the child’s age or state-approved grade-level standards:
  - Oral expression
  - Listening comprehension
  - Written expression
  - Basic reading skill
  - Reading fluency skills
  - Reading comprehension
  - Mathematics calculation
  - Mathematics problem solving
- The determination of whether a child is performing adequately for their age or meeting state-approved grade-level standards can be made by:
  - Reviewing the child’s progress in response to scientific, research-based intervention (RTI), and determining they are not making sufficient progress.
    - In other words, even when administered evidence-based interventions with fidelity, the student is not progressing. OR
  - The child exhibits a pattern of strengths and weaknesses in performance, achievement, or both relative to age, state-approved standards, or intellectual development that is determined by the group to be relevant to the identification of an SLD using appropriate assessments.
    - In other words, the IEP committee can analyze a child’s abilities through:
      - A comparison of their classroom performance and academic achievement to their same-age peers, grade-level expectations, and/or intellectual ability.
      - This means that standardized assessments administered through an evaluation can be considered, such as intellectual and achievement (i.e., academic) assessments, but so can performance in the classroom, interventions, and state and district assessments.
        
        An evaluation for Special Education must include a variety of assessment tools, including parent information. The assessments administered as part of a Special Education evaluation must be technically sound. No single assessment can be used as the sole determining factor for eligibility.
- The IEP committee must determine that the findings are not primarily due to:
  - A visual, hearing, or motor disability
  - An intellectual disability
  - Emotional disturbance
  - Cultural factors
  - Environmental or economic disadvantage
  - Limited English proficiency

Dyslexia, dyscalculia, and dysgraphia

Although there is not a single definition accepted as the definition of dyslexia, dyscalculia, or dysgraphia, the terms are often used and are important to understand. Furthermore, the US Department of Education released guidance for school districts to follow regarding dyslexia, dyscalculia, and dysgraphia. While these are not specifically listed as Special Education eligibilities, they can be included in reports if they are the basis for qualification. In other words, if a child has a diagnosis of dyscalculia and is then found to meet criteria for a Specific Learning Disability in math reasoning, the evaluation personnel can indicate this eligibility is consistent with the outside diagnosis of dyscalculia.

Dyslexia

Dyslexia is a reading disorder typically marked by difficulty understanding phonics and sound-symbol relationships. This means it is a language-based learning difference. This results in reading that is more effortful and less fluent, which can impact comprehension, vocabulary, and reading experiences.

Dyslexia characteristics

Dyslexia is often characterized by trouble with:

Word recognition
Word reading (i.e., decoding)
Accuracy
Fluency
Spelling

Dyslexia misconceptions

Not all students with dyslexia reverse letters and not all students who reverse letters have dyslexia. This is the case for their reading and writing.
It used to be widely accepted that dyslexia could not be identified until elementary school because signs do not appear until then. However, this is not the case. Since it is language-based, some children show signs in preschool. This is why states have started implementing dyslexia screeners. This has been a big push in Texas lately.
Vision problems do not cause dyslexia.
People with dyslexia can learn to read but their dyslexia never goes away.

Dyscalculia

Dyscalculia is a math disorder characterized by trouble learning, understanding, and performing math (e.g., facts, simple problems, reasoning, calculations). It is unclear whether there is a gender difference in prevalence.

Dyscalculia characteristics

Dyscalculia is often characterized by difficulty:

Understanding numerical concepts
Connecting numerals and words (e.g., 3 and three)
Memorizing math facts
Working with money (e.g., counting, making change)
Estimating time, speed, distance
Understanding math concepts and logic
Keeping numbers in mind while solving problems

Dyscalculia misconceptions

Dyscalculia is not uncommon but there is not as much research into it as their is into dyslexia and dysgraphia. Experts say it might occur as much as other learning disabilities and it often co-occurs with other learning problems.
It is not the number version of dyslexia. In other words, it’s not just reversing numbers. It is about difficulty understanding math concepts and developing number sense.
Similar to dyslexia, signs can show up in preschool such as trouble learning to count and understanding patterns.
It is not just anxiety about math.

Dysgraphia

Dysgraphia is a writing disorder marked by difficulty producing writing- putting thoughts on paper (or typing) and can include difficulties with spelling, grammar, punctuation, and handwriting.

Dysgraphia characteristics

Dysgraphia can be characterized by issues with:

Letter sizing
Letter spacing
Wrong or unusual spelling
Incorrect word choices
Slow and labored writing
Writing between the lines
Grip on writing utensils
Body positioning for writing
The amount of pressure used when writing
Letter reversals
Language processing
Connecting sounds and symbols (meaning they can verbally spell out a word but struggle to write it)

Dysgraphia misconceptions

People with dysgraphia are not lazy but are often worn out by the labor intensity of writing. This is similar to how labor-intensive reading and math are for people with dyslexia and dyscalculia.
Not everyone with dysgraphia has poor handwriting.
It is not the self-expression piece of writing that is the problem, but the labor that goes into producing writing can interfere with expression. In other words, the exhaustion from writing can interfere with thought processes.

Diagnosis

Now that the variations in diagnostic criteria and terminology have been outlined, how do you go about obtaining a learning disability diagnosis? There are many different avenues for this from public school evaluations to those performed by clinics. These are briefly outlined below.

Public school “diagnosis”

It is important to note that schools do not “diagnose” disabilities but they determine if a child meets criteria for Special Education eligibility. Parents can request for their area public school to evaluate their child for a learning disability. Similarly, staff can recommend a student to be evaluated. The district is not required to complete the evaluation, they just have to consider the request. Conversely, they are required to evaluate students who have suspected or diagnosed disabilities.

Typically, if the child is struggling and interventions have been tried, districts will proceed with an evaluation. If no concerns have been noted previously and no interventions have been needed or implemented, they are more likely to recommend interventions before an evaluation. However, this can get complicated and will be covered more in another blog post. It is a hard to strike a balance between educating children in their least restrictive environment (LRE) by providing interventions and not waiting too long for a child to show they are continuing to struggle before evaluating them for a possible disability. Furthermore, RTI is not a prerequisite for a Special Education evaluation.

Clinics, private practice, hospitals

Families can also choose to pursue an evaluation outside of the school by going through a local clinic, private practice, or hospital. These evaluations are typically completed by licensed professionals, trained to diagnose SLD. It is important for families to know the training of the person completing the evaluation as not everyone who completes these evaluations is trained to do so.

What is included in the evaluation

It is important for families to know what to expect when having an evaluation completed on their child.

Public school evaluation

If the public school system completes an evaluation on your child, there are specific requirements they are bound by law to meet. Those can be found here.

Outside of school evaluation

Evaluations completed by providers outside of public schools are not bound by the same criteria. There are legal and ethical guidelines they comply with, depending on their licensing board, but they are not governed by Special Education law. However, individuals who are licensed as school psychologists in private practice are well versed in Special Education law and can write the report more consistently with that if needed. This is highly beneficial in cases where parents would like to share the report with the school. While other professionals can write reports that can be shared as well, those reports often do not contain all of the legally required components for a school-based evaluation. This leads to the school often needing to supplement the evaluation before considering Special Education eligibility.

How the diagnosis is made

The criteria utilized to make the diagnosis varies depending on the setting the evaluation is completed in.

Public schools

Public schools determine if students meet the IDEIA criteria for SLD reviewed above as well as their state criteria for Special Education eligibility. They do not use any of the diagnostic criteria from the DSM-5 or ICD-11. However, as stated previously, they can reference diagnostic criteria and diagnoses in their reports (e.g., dyscalculia). There are several ways schools can go about making the determination of eligibility and some of the most common are reviewed below.

Public schools and RTI

As previously discussed, public schools can determine a child meets criteria for an SLD based on their progress in RTI as well as all other relevant information. This means that a student’s performance can be compared to grade and age expectations as well as the performance of peers in class to determine if they are making sufficient progress or not. However, many feel that a student’s lack of progress in RTI cannot be the sole determining factor of whether they meet criteria for SLD. This is because of many issues related to RTI, particularly that it is not referenced by name in federal law and there are no standardized procedures for the use and implementation of RTI.

Public schools and the discrepancy model

For years, the discrepancy model was required for SLD identification. The IDEIA reauthorization in 2004 changed this. States can choose to use the discrepancy model, other models, or a combination. According to Understood.org, 39 states still allow the use of the discrepancy model while 11 states prohibit its use.

The discrepancy model involves examining the difference between a child’s IQ and their academic achievement. This is often based on formal achievement tests administered as part of the Special Education evaluation but can also involve an informal review of classroom data such as district assessments and reading level.

There are many concerns about the discrepancy model because there are no set standards for identifying discrepancies that result in eligibility. In other words, there is not set criteria for how big the difference needs to be for a student to qualify. This means they could qualify in one state, or even one city, and not in the next.

Pattern of strengths and weaknesses (PSW)

Several districts have moved to PSW models where the overall IQ is not the focus. Instead, the pieces that comprise an overall IQ are examined (e.g., processing speed, working memory, long-term retrieval) to determine if there are any areas of cognitive weakness. If there are areas of weakness, the evaluator looks for a pattern to this weakness. The pattern indicates that a student’s areas of weakness are somewhat predictable. Then, academics are evaluated to see if there are weaknesses. This is often done through the administration of achievement (i.e., academic) assessments. Academic weaknesses, if any, are then compared to cognitive weaknesses to see if the cognitive weaknesses explain the academic difficulties.

It is important to note that these models do not diagnose SLD, they are tools that can be utilized by qualified professionals to assist with the determination of whether there is an SLD present or not. In Texas, evaluations for SLD are required to include a PSW.

There are many PSW models out there and they can be confusing for parents who do not work with these models on a daily basis. Two of the more common ones used in Texas are the cross-battery (XBA) model and the C-SEP model. The report written should indicate the model used and provide an explanation. The PSW models all work to identify the pattern of strengths and weaknesses between cognitive ability and academic performance. These models are not reviewed in depth as the breadth of information needed to describe them would be overwhelming in the context of this article.

Outside of school evaluation

The criteria utilized by outside professionals to diagnose SLD varies. It depends on personal and theoretical philosophies. Similar to schools, they should explain how their determination was made. Ultimately, their decision is guided by DSM-5 and/or ICD-11 criteria. It is not uncommon for outside professionals do abide by a more discrepancy-type model as it lends itself well to the data needed to determine if a child meets the diagnostic criteria.

Across settings

No matter where you have your child evaluated, evaluators are required to ensure that all other variables that could be causing the difficulties are not the primary reason for the difficulties. For example, if a child does poorly on many academic assessment components but needs glasses, their performance could have been completely skewed by the lack of glasses. Similarly, if the child is an English language learner, their performance could be impacted due to their lack of exposure to the English language.

Keep in mind

It is important to keep in mind that SLDs are commonly co-morbid (i.e., co-occur) with other conditions. ADHD is the most common co-morbid condition. Anxiety disorder, mood disorder, and language disorder are also commonly co-morbid with SLD as well as conduct disorder. It is not uncommon for children with learning difficulties to have behavior problems, low self-esteem, behavior problems, and emotional concerns.

A look at the numbers

While students can have an SLD and not be in Special Education, looking at the numbers in terms of SLD Special Education eligibility shows a snapshot of how prevalent SLD is. During the 2018-2019 school year, there were 8,909 students between the ages of 3 and 5 eligible for Special Education under the educational condition of SLD. Similarly, there were 2,377,739 students ages 6-21 receiving Special Education services under the educational condition of SLD.

At that time, there were 815,010 students ages of 3-5 and 6,315,228 students ages 6-11 receiving Special Education services throughout the United States. That is a total of 7,130,238 students ages 3-21. This translates to 1.09% of students ages 3-5 and 37.65% of students ages 6-21 receiving Special Education services qualified for those services due to a learning disability. Overall, the educational condition of SLD was an eligibility for 33.47% of students eligible for Special Education.

Texas

In Texas during the 2018-2019 school year, there were 46 students ages 3-5 and 163,330 ages 6-21 receiving Special Education services under the educational condition of SLD. At that time, the number of students ages 3-21 in Special Education (in Texas) was 532,185 with 53,750 being ages 3-5 and 478,435 being ages 6-21. This means 0.09% of students ages 3-5 and 34% of students ages 6-21 receiving Special Education services qualified for those services due to a learning disability. Overall, the educational condition of Specific Learning Disability was an eligibility for 30.70% of students eligible for Special Education in Texas.

When to evaluate

Making the decision to have your child evaluated is never easy. It is hard to know the exact right moment they should be tested where you will catch whatever might going on with them without waiting for them to fail or testing too early. School evaluation staff battle the same thing. Remember that it is not a decision you have to make alone. Talk with your family, the teacher(s), school staff, outside professionals, and do your research. Use all of that information to make the best determination for your child. You will always know your child best. Trust that. Parent intuition is often right. It may not be an SLD or whatever you suspect in the end, but it may be something. Your concerns could lead to a diagnosis. It is also okay if it does not lead to any diagnosis. Your concerns may be typical for a child that age or in those circumstances. That is okay, too.

Summary

Many types of concerns related to academic and school performance can lead parents to wonder if their child has a learning disability. It can be confusing to pursue a diagnosis as the criteria used is different in each setting (i.e., DSM-5, ICD-11, IDEIA) and familiar terms (i.e., dyslexia, dyscalculia, dysgraphia) are not formal diagnostic categories. There are also differences in the way diagnostic decisions are made from one professional to the next from discrepancy models to PSW models. Understanding all of these differences helps parents navigate the systems and find support for their children. Knowing what to look for and when to have a child evaluated can be tough for families. The hope is that families use the tools around them, including this blog, to make the best informed decision for their child as possible and that they are confident in those decisions. It takes a village.

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