V.7 #1 Social-Emotional Development - Learning Disabilities and the DSM V

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As educators, we are accustomed to the publication of new editions of well-used books. Sometimes new editions bring together accumulated knowledge and a deeper understanding of the topic under discussion; in these instances, the new edition is a welcome sight. The May 2013 publication of the Diagnostic and Statistical Manual of Mental Disorders, Fifth Edition (DSM V) (APA, 2013), is one of those welcome new editions. This compilation of diagnostic information and criteria brings together a wealth of new information learned over the last two decades of research in regard to numerous mental disorders, but specifically it re-invisions the concept of Learning Disabilities (LD). In the fourth edition of the DSM, the diagnostic category of Learning Disorders was placed under the section titled “Usually First Diagnosed in Infancy, Childhood or Adolescence.” Although that section identifier is typically correct, the DSM V places the renamed diagnostic category of Specific Learning Disorder under the section titled “Neurodevelopmental Disorders” capturing the life-long implications of this brain disorder. The information detailed in the DSM V contains descriptions, symptoms and other criteria that provide a common language for professionals as a way to assist in the diagnosis of LD. Why New Descriptors for LD?

The prevalence of LD among school-age children of various cultures ranges from 5-15%, demonstrating that this disorder afflicts a great number of individuals worldwide (APA, 2013). Over the past twenty years, much research in the field of LD has taken place, and with that research the community of professionals has gained new knowledge. This knowledge is reflected not only in the way that LD is assessed and diagnosed, but also in the way teachers and specialists’ work with students who have LD. The DSM IV had placed an individual’s learning disorder into one of three categories – Specific Reading Disorder, Specific Math Disorder and Disorders of Written Expression. As professionals working with students experiencing these difficulties, we know that these three classifications frequently overlap; research has substantiated that the three disorders are highly inter-related and should not be considered separate (Tannock, 2013). Therefore, the DSM V (APA, 2013) has revised the diagnosis into a single category, Specific Learning Disorder, which captures the overall difficulty experienced in the academic domain; allowing the diagnostician to specify the details of the areas of academic impairment as well as the severity of the disorder: mild, moderate or severe. DSM V Diagnostic Criteria

The team of experts who worked on the development of the DSM V – LD diagnostic category, identified four diagnostic criteria that need to be met for the diagnosis of LD. In the evaluation of an individual for an LD diagnosis, there is an examination and synthesis of information pertaining to development, medical history, family circumstances, and educational reports, in addition to the administration of standardized psycho-educational assessment tools. The comprehensive evaluation process strives to bring the identification of students with LD in line with federal legislative guidelines specified in the Individuals with Disabilities Education Improvement Act of 2004 (IDEIA 2004). This historic federal legislation specified that the identification of LD in school children did not need to be made utilizing the standard IQ- Achievement discrepancy formula; opening up the educational community to the possibilities of the Response to Intervention (RTI) model now utilized throughout the country. Briefly summarized, the four diagnostic criteria are: (adapted from APA, DSM V, 2013)

A. A persistent difficulty learning academic skills for at least 6 months despite intervention targeting the area(s) of difficulty. Many schools use a RTI model of academic skill assessment and progress monitoring to determine the effectiveness of interventions. The areas of documented academic skill difficulties include: 1. Word decoding and word reading fluency 2. Reading comprehension 3. Spelling 4. Writing difficulties such as grammar, punctuation, organization, and clarity 5. Number sense, fact and calculation 6. Mathematical reasoning B. The affected academic skills are substantially below expectations given the individual’s age and result in impaired functioning in school, at work and in activities of daily living. C. LD is readily apparent in the early years, however it is not to be diagnosed until the onset of school years; in some individuals the disorder is not apparent until the onset of a demand for higher-level skills. D. The academic and learning difficulties occur in the absence of: 1. Intellectual Disabilities 2. Visual or hearing impairments 3. Mental disorders (e.g. depression, anxiety, etc.) 4. Neurological disorders 5. Psycho-social difficulty 6. Language differences 7. Lack of access to adequate instruction

Diagnostic Clarity for LD

LD typically occurs in individuals identified as having normal intelligence, although it may also occur in individuals identified as gifted. Despite the level of measured intelligence, the individual persists in having difficulties learning and using academic skills. LD also can affect an individual’s adaptive skills across the lifespan. Difficulties with relationships, overall poorer mental health and higher rates of unemployment are some characteristics associated with LD. However, the presentation of symptoms is different in all individuals, and the unique characteristics that present in each person have to be identified and addressed. The lack of consistency in the presentation of symptoms continues to make LD a difficult diagnosis to make and impedes the formation of a clear and concise definition of the disorder. However, clarity in classification is important and serves multiple purposes. A concise classification aids in communication about the disorder to researchers, specialists, teachers, parents and the individual with a LD. Furthermore, it enables individuals to retrieve information about the disorder effectively. The ability to describe and predict outcomes based on the disorder also leads to a cohesive theory about the disorder (Brueggemann, Kamphaus, & Dombrowski, 2008). LD Understood as an Academic Disorder

Research over the last five years has sought to clarify the definition of LD (Brueggemann, et al., 2008). The consensus captured in the DSM V defines LD as a disorder of low academic achievement. Opponents of this approach have indicated that relying on a cut-off score from a standardized achievement test presents with the same problematic formula that is inherent in the IQ-Achievement discrepancy formula and relies on a single indicator of performance. However proponents argue, and DSM V includes as a requirement, the use of multiple indicators in the diagnosis of LD as a way to provide evidence of impaired functioning. Brueggemann and colleagues (2008) have advocated for the inclusion in the definition of LD a functional impairment standard, as put forth in the Americans with Disabilities Act of 1990 (ADA). ADA’s standard is that an individual is only disabled if their impairment limits their performance relative to the average person’s performance. By including functional impairment in the diagnosis, the average person standard is met and the requirement for multiple indicators of performance would also have been met. Furthermore, identifying areas of functional impairment will help to clarify the uniquely individual profile of the person with LD by identifying interpersonal relation abilities and self-care skills along with the person’s performance in the school setting. In that way, the individual with LD can be recognized and served based on the unique set of characteristics that their disorder presents. As always, if you suspect a student in your class is experiencing a Specific Learning Disorder, talk to the school psychologist or other designated professionals in the school. Specific Learning Disorder is a life-long disability that does not remit on it’s own, the individual must be provided with targeted instruction in the areas they experience difficulty. References

American Psychiatric Association: Diagnostic and Statistical Manual of Mental Disorders, Fifth Edition. Arlington, VA, American Psychiatric Association, 2013. Brueggemann, A.E., Kamphaus, R.W., & Dombrowski, S.C. (2008). An impairment model of learning disability diagnosis. Professional Psychology: Research and Practice, 39 (4), 424-430. Tannock, R. (2013, May 1). Rethinking learning disorders. Retrieved from: http://blogs.scientificamerican.com/mind-guest-blog/2013/05/01/rethinking- learning-disorders/ Micheline Malow, Ph.D. is an Associate Professor in the Department of Special Education at Manhattanville College located in Purchase, New York. Dr. Malow teaches courses in Foundations of Special Education and Child Development. She has presented at numerous professional conferences and published articles on risk taking behavior and students with disabilities. She has a co-authored book with Greenwood Press, Adolescents and Risk.Dr. Malow can be reached at micheline.malow@mville.edu.

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