SPECIFIC LEARNING DISORDER

Specific learning disorder in youth is a neurodevelopmental disorder produced by the

interactions of heritable and environmental factors that influence the brain’s ability to efficiently
perceive or process verbal and nonverbal information. It is characterized by persistent difficulty
learning academic skills in reading, written expression, or mathematics, beginning in early childhood,
that is inconsistent with the overall intellectual ability of a child. Children with specific learning
disorder often find it difficult to keep up with their peers in certain academic subjects, whereas they
may excel in others. Academic skills that may be compromised in specific learning disorder include
reading single words and sentences fluently, written expression and spelling, and calculation and
solving mathematical problems. Specific learning disorder results in underachievement that is
unexpected based on the child’s potential as well as the opportunity to have learned more. Specific
learning disorder in reading, spelling, and mathematics appears to aggregate in families. There is an
increased risk of four to eight times in first-degree relatives for reading deficits, and about five to ten
times for mathematics deficits, compared to the general population. Specific learning disorder
occurs two to three times more often in males than in females. Learning problems in a child or
adolescent identified in this manner can establish eligibility for academic services through the public
school system.

Specific learning disorder of all types affects approximately 10 percent of youth. This
represents approximately half of all public school children who receive special education services in
the United States. In 1975, Public Law 94–142 (the Education for All Handicapped Children Act now
known as the Individual with Disabilities Education Act [IDEA]) mandated all states to provide free
and appropriate educational services to all children. Since that time, the number of children
identified with learning disorders has increased, and a variety of definitions of learning disabilities
have arisen. To meet the criteria for specific learning disorder, a child’s achievement must be
significantly lower than expected in one or more of the following: reading skills, comprehension,
spelling, written expression, calculation, mathematical reasoning, and/or the learning problems
interfere with academic achievement or activities of daily living. It is common for specific learning
disorder to include more than one area of skills deficits.

Children with specific learning disorder in the area of reading can be identified by poor word
recognition, slow reading rate, and impaired comprehension compared with most children of the
same age. Current data suggest that most children with reading difficulties have deficits in speech
sound processing skills, regardless of their intelligence quotient (IQ), and in DSM-5, there is no
longer a diagnostic criterion for specific learning disorder comparing the specific deficit to overall IQ.
Current consensus is that children with reading impairment have trouble with word recognition and
“sounding out” words because they cannot efficiently process and use phonemes (the smaller bits of
words that are associated with particular sounds). A recent epidemiologic study found four profiles
including (1) weak reading, (2) weak language, (3) weak math, or (4) combined weak math and
reading, accounting for 70 percent of children with specific learning impairments. Low scores in
short-term memory for speech sounds characterized the profile with weak language, whereas, low
speech sound awareness was associated with the weak reading group, but not the weak language
group. Finally, in another recent study it was found that the weak math group did not show speech
sound deficits.
Specific Learning Disorder with Impairment in Reading
Reading impairment is present in up to 75 percent of children and adolescents with specific
learning disorder. Students who have learning problems in other academic areas most commonly
experience difficulties with reading as well.

Reading impairment is characterized by difficulty in recognizing words, slow and inaccurate

reading, poor comprehension, and difficulties with spelling. Reading impairment is often comorbid
with other disorders in children, particularly, ADHD. The term developmental alexia was historically
used to define a developmental deficit in the recognition of printed symbols. This was simplified by
adopting the term dyslexia in the 1960s. Dyslexia was used extensively for many years to describe a
reading disability syndrome that often included speech and language deficits and right–left
confusion. Reading impairment is frequently accompanied by disabilities in other academic skills,
and the term dyslexia remains as an alternate term for a pattern of reading and spelling difficulties.

Epidemiology
An estimated 4 to 8 percent of youth in the United States have been identified with dyslexia,
encompassing a variety of reading, spelling, and comprehension deficits. Three to four times as
many boys as girls are reported to have reading impairments in clinically referred samples. In
epidemiological samples, however, rates of reading impairments are much closer among boys and
girls. Boys with reading impairment are referred for psychiatric evaluation more often than girls due
to comorbid ADHD and disruptive behavior problems. No clear gender differential is seen among
adults who report reading difficulties.
Comorbidity
Children with reading difficulties are at high risk for additional learning deficits including
mathematics and written expression. The DSM-5 Language disorder, also known as specific language
impairment, has traditionally been viewed as distinct from dyslexia and dyscalculia. Children with
language disorder have poor word knowledge, limited abilities to form accurate sentence structure,
and impairments in the ability to put words together to produce clear explanations. Children with
language disorder may have delayed development of language acquisition, and difficulties with
grammar and syntactical knowledge. Specific learning disorder in the areas of reading and
mathematics frequently occur comorbidly with language disorder. In one study, it was found that
among dyslexic samples, 19 percent to 63 percent also have language impairment. Conversely,
reading impairment has been found in 12.5 percent to 85 percent of individuals with language
disorder. In twin studies, reading impairments were found to be significantly higher in those children
with specific learning impairment and in family members of children with the disorder. There are
also high rates of comorbidity between reading impairment and mathematics impairment; in some
studies the comorbidity has been reported to be up to 60 percent. It appears that children with both
reading and math impairment may perform more poorly in mathematics; however, the reading skills
of the comorbid children were no different from children who had only reading disorder and not
math disorder. Comorbid psychiatric disorders are also frequent, such as ADHD, Oppositional Defiant
Disorder, Conduct Disorders, and Depressive Disorders, especially in adolescents. Data suggest that
up to 25 percent of children with reading impairment may have comorbid ADHD. Conversely, it is
estimated that between 15 and 30 percent of children diagnosed with ADHD have specific learning
disorder. Family studies suggest that ADHD and reading impairment may share some degree of
heritability. Youth with reading impairments have higher than average rates of depression on self-
report measures and experience higher levels of anxiety symptoms than children without speciϧc
learning disorder. Furthermore, children with reading impairment are at increased risk for poor peer
relationships and exhibit less skill in responding to subtle social cues.

Etiology
Data from cognitive, neuroimaging, and genetic studies suggest that reading impairment is a
neurobiological disorder with a significant genetic contribution. It reflects a deficiency in processing
sounds of speech sounds, and thus, spoken language. Children who struggle with reading most likely
also have a deficit in speech sound processing skills. Children with this deficit cannot effectively
identify the parts of words that denote specific sounds, leading to difficulty in recognizing and
“sounding out” words. Youth with reading impairment are slower than peers in naming letters and
numbers. The core deficits for children with reading impairment include poor processing of speech
sounds and deficits in comprehension, spelling, and sounding out words.

Because reading impairment typically includes a language deficit, the left brain has been
hypothesized to be the anatomical site of this dysfunction. Several studies using magnetic resonance
imaging (MRI) studies have suggested that the planum temporale in the left brain shows less
asymmetry than the same site in the right brain in children with both language disorders and specific
learning disorder. Positron emission tomographic (PET) studies have led some researchers to
conclude that left temporal blood flow patterns during language tasks differ between children with
and without learning disorders. Cell analysis studies suggest that in reading impaired individuals, the
visual magnocellular system (which normally contains large cells) contains more disorganized and
smaller cell bodies than expected. Studies indicate that 35 to 40 percent of first-degree relatives of
children with reading deficits also have reading disability. Several studies have suggested that
phonological awareness (i.e., the ability to decode sounds and sound out words) is linked to
chromosome 6. Furthermore, the ability to identify single words has been linked to chromosome 15.
Impairment in reading and spelling has now been linked to susceptibility loci on multiple
chromosomes, including chromosomes 1, 2, 3, 6, 15, and 18. Although a recent research study
identified a locus on chromosome 18 as a strong influence on single word reading and phoneme
awareness, generalist genes have also been implicated as responsible for learning disorders.

Several historical hypotheses about the origin of reading deficits are now known to be
untrue. The first myth is that reading impairments are caused by visual–motor problems, or what
has been termed scotopic sensitivity syndrome. There is no evidence that children with reading
impairment have visual problems or difficulties with their visual–motor system. The second false
theory is that allergies can cause, or contribute to, reading disability. Finally, unsubstantiated
theories have implicated the cerebellar–vestibular system as the source of reading disabilities.

Research in cognitive neuroscience and neuropsychology supports the hypothesis that

encoding processes and working memory, rather than attention or long-term memory, are areas of
weakness for children with reading impairment. One study found an association between dyslexia
and birth in the months of May, June, and July, suggesting that prenatal exposure to a maternal
infectious illness, such as influenza, in the winter months may contribute to reading disabilities.
Complications during pregnancy and prenatal and perinatal difficulties are common in the histories
of children with reading disabilities. Extremely low birth weight and severely premature children are
at higher risk for specific learning disorder. Children born very preterm have been noted to be at
increased risk of minor motor, behavioral, and specific learning disorder.

An increased incidence of reading impairment occurs in intellectually average children with

cerebral palsy and epilepsy. Children with postnatal brain lesions in the left occipital lobe, resulting
in right visual-field blindness, as well as youth with lesions in the splenium of the corpus callosum
that blocks transmission of visual information from the intact right hemisphere to the language
areas of the left hemisphere experience reading impairments. Children malnourished for long
periods during early childhood are at increased risk of compromised performance cognition,
including reading.

Clinical Features
Children with reading disabilities are usually identified by the age of 7 years (second grade).
Reading difficulty may be apparent among students in classrooms where reading skills are expected
as early as the first grade. Children can sometimes compensate for reading disorder in the early
elementary grades by the use of memory and inference, particularly in children with high
intelligence. In such instances, the disorder may not be apparent until age 9 (fourth grade) or later.
Children with reading impairment make many errors in their oral reading. The errors are
characterized by omissions, additions, and distortions of words. Such children have difficulty in
distinguishing between printed letter characters and sizes, especially those that differ only in spatial
orientation and length of line. The problems in managing printed or written language can pertain to
individual letters, sentences, and even a page. The child’s reading speed is slow, often with minimal
comprehension. Most children with reading disability have an age-appropriate ability to copy from a
written or printed text, but nearly all spell poorly.

Associated problems include language difficulties: discrimination and difficulty in sequencing

words properly. A child with reading disorders may start a word either in the middle or at the end of
a printed or written sentence. Most children with reading disorder dislike and avoid reading and
writing. Their anxiety is heightened when they are confronted with demands that involve printed
language. Many children with specific learning disorder who do not receive remedial education have
a sense of shame and humiliation because of their continuing failure and subsequent frustration.
These feelings grow more intense with time. Older children tend to be angry and depressed and
exhibit poor self-esteem.

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.

Course and Prognosis

Children with reading disability may gain knowledge of printed language during their first 2
years in grade school, without remedial assistance. By the end of the first grade, many children with
reading problems, in fact, have learned how to read a few words; however, by the third grade,
keeping up with classmates is exceedingly difficult without remedial educational intervention. When
remediation is instituted early, in milder cases, it may not be necessary after the first or second
grade. In severe cases and depending on the pattern of deficits and strengths, remediation may be
continued into the middle and high school years.
Treatment
Remediation strategies for children with reading impairments focus on direct instruction
that leads a child’s attention to the connections between speech sounds and spelling. Effective
remediation programs begin by teaching the child to make accurate associations between letters
and sounds. This approach is based on the theory that the core deficits in reading impairments are
related to difficulty recognizing and remembering the associations between letters and sounds. After
individual letter-sound associations have been mastered, remediation can target larger components
of reading such as syllables and words. The exact focus of any reading program can be determined
only after accurate assessment of a child’s specific deficits and weaknesses. Positive coping
strategies include small, structured reading groups that offer individual attention and make it easier
for a child to ask for help.

Children and adolescents with reading difficulties are entitled to an individual education
program (IEP) provided by the public school system. Yet, for high school students with persistent
reading disorders and ongoing difficulties with decoding and work identification, IEP services may
not be sufficient to remediate their problems. A study of students with reading disorders in 54
schools indicated that, at the high school level, specific goals are not adequately met solely through
school remediation. It is likely that high schoolers with persisting reading difficulties may have
greater benefit from individualized reading remediation.

Reading instruction programs such as the Orton Gillingham and Direct Instructional System
for Teaching and Remediation (DISTAR) approaches begin by concentrating on individual letters and
sounds, advance to the mastery of simple phonetic units, and then blend these units into words and
sentences. Thus, if children are taught to cope with graphemes, they will learn to read. Other
reading remediation programs, such as the Merrill program, and the Science Research Associates,
Inc. (SRA) Basic Reading Program, begin by introducing whole words first and then teach children
how to break them down and recognize the sounds of the syllables and the individual letters in the
word. Another approach teaches children with reading disorders to recognize whole words through
the use of visual aids and bypasses the sounding-out process. One such program is called the Bridge
Reading Program. The Fernald method uses a multisensory approach that combines teaching whole
words with a tracing technique so that the child has kinesthetic stimulation while learning to read
the words.