|Year : 2019 | Volume
| Issue : 3 | Page : 276-278
Learning disorder or learning disability: Time to rethink
Varsha Vidyadharan, Harish M Tharayil
Department of Psychiatry, Government Medical College, Kozhikode, Kerala, India
|Date of Web Publication||17-May-2019|
Dr. Varsha Vidyadharan
Department of Psychiatry, Government Medical College, Kozhikode - 673 008, Kerala
Source of Support: None, Conflict of Interest: None
|How to cite this article:|
Vidyadharan V, Tharayil HM. Learning disorder or learning disability: Time to rethink. Indian J Psychol Med 2019;41:276-8
Learning disorders (LDs) or specific learning disorders (SLDs) are a group of neurodevelopmental disorders that manifest during formal schooling, characterized by persistent and impairing difficulties in learning foundational academic skills for reading, writing, and/or mathematics. These are diagnosed when there are specific deficits in an individual's ability to perceive or process information efficiently and accurately. There must be significant impairment in the specified scholastic skill, and this impairment should not be due to sensory/motor deficits, mental retardation, low general intelligence, poor teaching, lack of adequate stimulation, or any such external causes. This category is called “Specific developmental disorders of scholastic skills” in International Classification of Diseases 10th Edition (ICD-10). It is renamed as “Developmental learning disorder” in the recently released ICD-11 and subtyped as those with impairment in reading, written expression, mathematics, and with other specified impairment of learning. ICD-10 subtypes were specific reading disorder, specific spelling disorder, disorder of arithmetical skills, and mixed types.
LD exists worldwide and occurs in students irrespective of their mother-tongue or medium of instruction. LDs are a major cause for academic underachievement in young children. Perhaps, the most socially significant feature of LD is their invisible and seemingly benign nature, with long-term adverse effects on the scholastic achievement of affected children. Delayed and conflicting diagnoses are often common, leading to delayed intervention.
In this brief article, we intend to highlight the confusion prevailing in this area by the use of two different terms – “learning disorder” and “learning disability.” Nelson's Textbook of Paediatrics uses the term LD for conditions with neurodevelopmental dysfunction affecting reading, writing, and calculations. The subclassification of this is in complete agreement with the systems used in ICD-11 and Diagnostic and Statistical Manual 5th edition (DSM-5). They have not used the term “learning disability.” Intellectual disability is the term used for mental retardation.
Comprehensive Textbook of Psychiatry and Rutter's Textbook of Child and Adolescent Psychiatry also use the same nomenclature and subclassification as in ICD-11/DSM-5. Clinical practice guidelines by Indian Psychiatry Society also uses the term LD. The guidelines prepared by them defines the terms learning difficulty, disorder, and disability. According to the guidelines learning difficulty is a mild form where the child has only mild difficulty in particular areas such as reading or writing, and on standardized testing of achievements may not be substantially below the expected level, whereas in LD the child has substantial difficulty and is evident on standardized testing, and the difficulty can be overcome to a significant extent by remedial education. These guidelines define learning disability when the child has severe difficulty in particular areas that are evident on standardized test of achievement, and in spite of adequate therapeutic efforts there may not be any significant improvement. So it is more like a spectrum of increasing severity from learning difficulty to disability. Though there is some merit in this conceptualization, it is not clear whether such an approach is supported by empirical evidence. In real world one has to give a diagnosis to a child when he or she is brought for assessment. This helps the child to get educational benefits during studies and in examinations, suggesting that one has to wait till interventions may not work in practice. But a few authors, mainly those from the United Kingdom (UK), use the term “learning disability” to denote intellectual developmental disability, which is termed mental retardation in ICD-10 and intellectual developmental disorder in DSM-5. Intellectual delay, as we know, causes poor scholastic performance in children, but it is characterized by global developmental delay, including delayed milestones of development, smaller head circumference, etc. The subcategories of this in ICD-10, based on IQ scores, are mild, moderate, severe, and profound.
But “Essential Paediatrics” by OP Ghai uses the term “learning disability” to denote the condition referred to as a LD by all the above authors except those from the UK. Dyslexia, dysgraphia, dyscalculia, and reading comprehension difficulty (which are listed under SLD in DSM-5/ICD-10 and -11) are wrongly listed as subcategories here. This confusion seems to be present in other Indian literature too. In the practice guidelines by clinical psychologists, the terminology used is learning disability. Karande et al. use the term “learning disability” to describe the entity learning disorder of ICD-11 and DSM-5. Prathibha Karanth and Prema use the term “learning disability” as a descriptive term for children with complex learning problems.
The Indian Academy of Paediatrics has published a consensus statement on this condition. Unfortunately, they too use the term specific learning disability. But while detailing this condition, they give a description which makes it clear that they refer to SLD as defined in ICD-11 and DSM-5.
The Government of India has passed a new act covering all disabilities. This new Right of Persons with Disabilities Act (RPWD Act) also uses the term “learning disability” for “learning disorder.” Equating two conditions mental retardation and LD creates difficulties both for care providers and patients. The use of the term “disability” in the name of a medical condition is not acceptable as it creates conceptual confusion. A disorder is a medical condition that may or may not give rise to disability depending on its severity. Disability is the functional disadvantage suffered by a person affected by that condition. It is etiology-neutral, because the same disability could be the result of different disorders. In this context, poor academic ability (disability) could be due to different causes such as intellectual deficits, mental illness, poor motivation/teaching, or SLD. So, using the word disability in the name of one of the conditions that cause the disability is confusing.
From the above discussions, it is clear that the term learning disability is used in different contexts with different meanings. “Specific learning disability” is a term used by persons working in the educational sector. It probably covers all conditions including LD and some others as well. But it lacks a clear definition and criteria for diagnosis. Use of this term has led to increased confusion and lack of access to appropriate interventions for affected children. The management is entirely different for the conditions grouped as SLD. But unfortunately, some doctors too use these terms interchangeably. A possible explanation of this could be the fact that children with such problems and their parents have multiple stakeholders such as school teachers (rural/urban, English medium/local language medium, CBSE/ICSE/Local regulatory boards), parents themselves from diverse backgrounds, educationists, right-activists, law-makers, administrators, pediatricians, and psychiatrists, who possibly have a tendency to use the terms in their “common sense” or “generic sense.” Things get complicated by lack of awareness and understanding of this entity among stakeholders. Nonetheless, the scenario is improving with time.
The lack of a proper definition leads to wide variation in the prevalence rates and makes planning for remedial resources difficult. The studies are difficult to interpret because of terminological confusion. LD probably affects around 5–10% of school-going children. Suresh and Sebastian report on an epidemiological survey conducted in rural Kerala to detect suspected cases of developmental language disorders and language delay using a six-item questionnaire. Prevalence was 9.5% among children aged 5–12 years and 9.94% among those aged 13–16 years. But this number may not be of children with LD as defined above. In another study, among children with poor scholastic performance referred to a Child Guidance Clinic in Kerala, 55.8% were found to have LD.
In the background of this confusion, we suggest that all medical personnel from all specialties stick to the single term “specific learning disorder” as defined in Nelson's textbook and ICD-11/DSM-5. A search of “MeSH database” of PubMed using the term “specific learning disability” did not yield any results. This further confirms that this term is not used by medical personnel. In the United States, there is a federal law called “Individuals with Disabilities Education Act (IDEA),” which covers educational benefits for children with learning-related problems. This uses the term “specific learning disability” in a way similar to that of our RPWD Act. But the American Psychiatric Association still continues to use the term LD, and they have not changed the terminology to match the legal term. Hence, there is no legal compulsion for medical personnel to modify our diagnostic terminology. Disability boards can assess and quantify disability and may mention in the certificate as such. The terminology of learning disability has not entered into any official diagnostic system. We are bound to uphold our systems to encourage proper diagnosis, treatment, planning and research for developing better treatments, as well as to uncover underlying mechanisms of disease.
Ideally, the term specific learning disability is best abandoned as its meaning differs in different contexts. This would help us to make a clear diagnosis in children presenting with scholastic backwardness and institute appropriate intervention without delay. It may also reduce the stigma associated with this condition. Otherwise, we may end up in the confused scenario as depicted in Book of Genesis in Holy Bible “Come, let us go down, and confuse their language there so that they will not understand one another's speech. So the LORD scattered them abroad from there over the face of all the earth” (Genesis 11: 7, 8).
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Conflicts of interest
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