Learning Disorders

Learning disabilities or disorders (LDs) refer to difficulties in a child’s ability to learn skills related to reading, writing, mathematics, or any combination of these. An estimated 5%−15% of school-age children worldwide are affected by an LD. The estimated lifetime prevalence of LD among children in the U.S. is 9.7%. To increase the chances of academic success and reduce the risk of associated emotional and behavioral problems, children with LDs should be identified early and supported in school. Children with undiagnosed LDs or those who do not receive interventions to address learning problems are at a higher risk for mental health diagnoses such as anxiety or depression.

Diagnosis

The Diagnostic and Statistical Manual of Mental Disorders, fifth edition (DSM-5) provides criteria for the diagnosis of a specific learning disorder. Unlike criteria in past editions, DSM-5 no longer requires a child to have an IQ-achievement discrepancy to qualify for the diagnosis.

DSM-5 Criteria for a 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. Inaccurate or slow and effortful word reading Difficulty understanding the meaning of what is read Difficulties with spelling Difficulties with written expression Difficulties mastering number sense, number facts, or calculation Difficulties with mathematical reasoning The selected academic skills are below those expected for the individual’s chronological age and interfere with their academic performance or affect activities of daily living. Learning difficulties begin during school-age years but do not manifest until the demands exceed the individual’s capacities. Learning difficulties are not accounted for by other diagnoses.

DSM-5 Criteria for a 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.
- Inaccurate or slow and effortful word reading
- Difficulty understanding the meaning of what is read
- Difficulties with spelling
- Difficulties with written expression
- Difficulties mastering number sense, number facts, or calculation
- Difficulties with mathematical reasoning
The selected academic skills are below those expected for the individual’s chronological age and interfere with their academic performance or affect activities of daily living.
Learning difficulties begin during school-age years but do not manifest until the demands exceed the individual’s capacities.
Learning difficulties are not accounted for by other diagnoses.

Based on the DSM-5, the clinician determines whether the individual meets criteria for a specific LD diagnosis and the severity of the disorder (mild, moderate, or severe):

LD with impairment in reading
LD with impairment in written expression
LD with impairment in mathematics

Types of Learning Disorders

Dyslexia refers to a pattern of difficulties with accurate or fluent word recognition, decoding, and spelling. It is not an all-encompassing term for someone who has impairments in reading.
Dysgraphia refers to difficulties with putting thoughts on paper. Problems with writing can include difficulties with spelling, grammar, punctuation, and handwriting.
Dyscalculia refers to difficulties with processing numerical information, understanding arithmetic facts, and performing calculations. It is not an all-encompassing term for someone who has impairments in mathematics.

Etiology

There is no known etiology for LD. Risk factors for LD include:

premature birth or low birth weight
family history of LD
history of speech and language delay
diagnosis of attention deficit-hyperactivity disorder (ADHD)
- ADHD and LD are common comorbid diagnoses; if a child presents with one, they should be screened for the other.
male sex
specific genetic or medical diagnoses
- Turner syndrome
- myelomeningocele

Screening

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. (See a brief screening measure for LD.)

Response to intervention (RTI): 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. If a child needs further support that is not achieved with RTI, specific LD testing may be indicated.

Neuropsychological testing: Both cognitive testing and achievement testing are 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. A trained professional should administer, score, and interpret test results to provide an accurate diagnosis.

Differential Diagnosis

The differential for LD includes:

intellectual disability (ID) — LD can occur in individuals with normal IQ and in those with ID. In a child with ID, LDs are more pronounced than challenges associated with the ID alone.
ADHD — An individual with ADHD might present with challenges in school. In some children, symptoms of ADHD may not be related to specific challenges in learning or other specific academic skills. These children should be evaluated, keeping in mind that children with ADHD also may meet criteria for LD.
psychotic disorder
deaf or hard of hearing
vision impairment

Intervention

School supportive services are critical for children with LD. The three types of supportive services a child can receive for LD are:

Response to intervention (RIT): Classroom support is used to determine if a child who is struggling has LD.
504 plan: Accommodations under a 504 plan may include additional time for testing or preferred seating at the front of the classroom but would not include special education.
Individualized education program (IEP): Individuals with LD can qualify for special education after appropriate assessment (see Individuals with Disabilities Education Act [IDEA] in the section on Screening, Referrals, Evaluation, and Services in this rotation guide).