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DSM-IV

In DSM-IV, this disorder was a category called Learning Disorders.

Disorders

  1. Reading Disorder
  2. Mathematics Disorder
  3. Disorder of Written Expression
  4. Learning Disorder NOS

Differential Diagnosis

Normal variations in academic attainment, lack of opportunity, poor teaching, and cultural factors

Learning Disorders must be differentiated from normal variations in academic attainment and from scholastic difficulties due to lack of opportunity, poor teaching, or cultural factors. Inadequate schooling can result in poor performance on standardized achievement tests. Children from ethnic or cultural backgrounds different from the prevailing school culture or in which English is not the primary language and children who have attended class in schools where teaching has been inadequate may score poorly on achievement tests. Children from these same backgrounds may also be at greater risk for absenteeism due to more frequent illnesses or impoverished or chaotic living environments.

Impaired vision or hearing

Impaired vision or hearing may affect learning ability and should be investigated through audiometric or visual screening tests. A Learning Disorder may be diagnosed in the presence of such sensory deficits only if the learning difficulties are in excess of those usually associated with these deficits. Accompanying neurological or other general medical conditions should be recorded.

Mental Retardation

In Mental Retardation, learning difficulties are commensurate with general impairment in intellectual functioning. However, in some cases of Mild Mental Retardation, the level of achievement in reading, mathematics, or written expression is significantly below expected levels given the person's schooling and severity of Mental Retardation. In such cases, the additional diagnosis of the appropriate Learning Disorder should be made.

Pervasive Developmental Disorder

An additional Learning Disorder diagnosis should be made in the context of a Pervasive Developmental Disorder only when academic impairment is significantly below expected levels given the individual's intellectual functioning and schooling.

Communication Disorders

In individuals with Communication Disorders, intellectual functioning may have to be assessed using standardized measures of nonverbal intellectual capacity. In cases in which academic achievement is significantly below this measured capacity, the appropriate Learning Disorder should be diagnosed.

Other Learning Disorders

Mathematics Disorder and Disorder of Written Expression most commonly occur in combination with Reading Disorder. When criteria are met for more than one Learning Disorder, all should be diagnosed.

DSM-5

Diagnostic Criteria

A. 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 mathematics concepts, facts, or procedures to solve quantitative problems).

B. 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.

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 (e.g., as in timed tests, reading or writing lengthy complex reports for a tight deadline, excessively heavy academic loads).

D. 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 education 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.

Note: Specify all academic domains and subskills that are impaired. When more than one domain is impaired, each one should be recorded individually according to the following specifiers.

Specify if:

  • With impairment in reading:
    • Word reading accuracy
    • Reading rate or fluency
    • Reading comprehension
    • Note: 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 patterns of difficulties, it is important also to specify any additional difficulties that are present, such as difficulties with reading comprehension or math reasoning.
  • With impairment in written expression:
    • Spelling accuracy
    • Grammar and punctuation accuracy
    • Clarity or organization or written expression
  • With impairment in mathematics:
    • Number sense
    • Memorization of arithmetic facts
    • Accurate or fluent calculation
    • Accurate math reasoning
    • Note: Dyscalculia is an alternative term used to refer to a pattern of difficulties characterized by problems processing numerical information, leading to arithmetic facts, and performing accurate or fluent calculations. Is 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.

Recording Procedures

Each impaired academic domain and subskill of specific learning disorder should be recorded. Because of ICD coding requirements, impairments in reading, impairments in written expression, and impairments in mathematics, with their corresponding impairments in subskills, must be recorded separately. For example, impairments in reading and mathematics and impairments in the subskills of reading rate or fluency, reading comprehension, accurate or fluent calculation, and accurate math reasoning would be coded and recorded as specific learning disorder with impairment in reading, with impairment in reading rate or fluency and impairment in reading comprehension; specific learning disorder with impairment in mathematics, with impairment in accurate or fluent calculation and impairment in accurate math reasoning.

Differential Diagnosis

Normal variations in academic attainment

Specific learning disorder is distinguished from normal variations in academic attainment due to external factors (e.g., lack of educational opportunity, consistently poor instruction, learning in a second language), because the learning difficulties persist in the presence of adequate educational opportunity and exposure to the same instruction as the peer group, and competency in the language of instruction, even when it is different from one's primary spoken language.

Intellectual disability (intellectual developmental disorder)

Specific learning disorder differs from general learning difficulties associated with intellectual disability, because the learning difficulties occur in the presence of normal levels of intellectual functioning (i.e., IQ score of at least 70 ± 5). If intellectual disability is present, specific learning disorder can be diagnosed only when the learning difficulties are in excess of those usually associated with the intellectual disability.

Learning difficulties due to neurological or sensory disorders

Specific learning disorder is distinguished from learning difficulties due to neurological or sensory disorders (e.g., pediatric stroke, traumatic brain injury, hearing impairment, vision impairment), because in these cases there are abnormal findings on neurological examination.

Neurocognitive disorders

Specific learning disorder is distinguished from learning problems associated with neurodegenerative cognitive disorders, because in specific learning disorder the clinical expression of specific learning difficulties occurs during the developmental period, and the difficulties do not manifest as a marked decline from a former state.

Attention-deficit/hyperactivity disorder

Specific learning disorder is distinguished from the poor academic performance associated with ADHD, because in the latter condition the problems may not necessarily reflect specific difficulties in learning academic skills but rather may reflect difficulties in performing those skills. However, the co-occurrence of specific learning disorder and ADHD is more frequent than expected by chance. If criteria for both disorders are met, both diagnoses can be given.

Psychotic disorders

Specific learning disorder is distinguished from the academic and cognitive-processing difficulties associated with schizophrenia or psychosis, because with these disorders there is a decline (often rapid) in these functional domains.