F81.0, Specific reading disorder, specific reading disability, developmental dyslexia

F81.2, Mathematics disorder, specific learning disorder in mathematics, developmental acalculia

F81.81, Disorder of written expression, specific learning disorder with impairment in written expression, specific spelling disorder

F81.9, Learning disability, learning disorder NOS

Many disorders and syndromes affect neurodevelopmental domains (e.g., intellect, behavior) and sensory processes (e.g., hearing or vision impairment) and can mimic or contribute to specific learning disabilities. Consider the following factors that may influence learning and behavior:

• Adverse environments (such as a history of trauma or neglect)
• Absenteeism from the learning environment
• Inadequate instruction
• Linguistic/cultural differences
• Social-emotional/economic deprivation
• Other disorders:
  • Intellectual disability
  • Autism spectrum disorder
  • Visually impaired
  • Deaf and hard of hearing
  • Severe emotional or behavioral disturbances

The differential diagnostic process rules out other neurodevelopmental and sensory conditions. It approaches the assessment processes by taking into account documentation of the child’s academic and health history, unique individual developmental and behavioral profile, and detailed interpretation of test results in a multidimensional context to determine precise primary etiological factors for learning impairment. When these other factors considerably impair the student’s learning, the student may qualify for an Individualized Education Plan (IEP) or Section 504 School Accommodation Plan (a 504 Plan). Provide support with their educational process even if the student’s test results are not consistent with a specific learning disability.

Specific learning disabilities are identified through psychoeducational or neuropsychological assessments, neither of which are performed in the medical home. However, understanding the various types of assessments and what they offer can help guide clinicians and caregivers in the process.

The following are necessary components of an assessment for specific learning disabilities:

• Documentation in the specific area of academic underachievement (e.g., reading)
• Analysis of several developmental domains to reach diagnostic certainty. Intelligence and academic testing are often necessary for a specific learning disability diagnosis. However, it is important to recognize that a diagnosis should not depend only on test results.
• A holistic data-gathering approach (e.g., behavioral characteristics, social functioning). Thus, a comprehensive assessment, including one that considers an individual’s strengths and weaknesses, is necessary for determining the primary or contributing cause of academic underachievement and diagnosis of a specific learning disability diagnosis. As a case example, a language impairment may reduce an individual’s ability to perform well on specific tests. Thus, the interpretation of test results must take into account all aspects of the child’s neurodevelopmental profile. Moreover, specific formulaic approaches to diagnosing a specific learning disability diagnosis should not be overly relied on (e.g., discrepancy model).

Psychoeducational testing performed by specialists in the school setting generally includes intellectual, achievement, and parent and teacher behavioral checklists to determine a potential learning difficulty. If testing identifies 1 or more significant learning impairments, the school and family work together to develop School Accommodations: IEPs & 504s to address the child’s academic underachievement with goals and other strategies provided under an “educational classification.” School testing is typically interdisciplinary and benefits from clinician documentation about the child.

The public school system has traditionally identified learning disabilities through the Discrepancy Model. For instance, if the child’s intellectual score is greater than their achievement score by a certain degree determined by a formula specific to each state, then a learning disability is identified. Since 2004, school districts have increasingly used alternative assessment methods to complement psychoeducational assessment, including documenting ongoing underachievement to determine if a student qualifies for special education services due to a learning disability. Some school systems use their data from Response to Intervention (RTI) programming to identify learning difficulties and subsequently provide classroom interventions without psychoeducational testing.

Clinician’s Role
The medical home can assist families working with their school, usually starting with the classroom teacher, counselor, special educator, or administrator, to request an evaluation for learning impairments following the school and district protocol. If the family consents to share information between the school and primary care team, the clinician’s documentation about the child’s development, known diagnoses, and suggestions for interventions can assist the school in understanding the bigger picture.

A neuropsychological evaluation is a comprehensive assessment that affords a differential diagnosis of a specific learning disability diagnosis, ADHD, and other potential conditions and allows detailed testing of multiple domains of neurodevelopmental functioning to understand better the underpinnings of a child’s potential learning problem. A battery of neuropsychological tests would typically include parent and teacher checklists and measures of intelligence, achievement, attention, memory, processing and processing speed, problem-solving and reasoning, language and visual/spatial skills, fine motor skills, and social-emotional functioning.

Given the complexity of training, resources, time, and other aspects that go into such an assessment, school systems are not equipped to administer a neuropsychological evaluation. A psychologist typically performs a neuropsychological evaluation at an assessment center or private practice, not through the school district. There can be significant costs associated with a neuropsychological evaluation; insurance coverage varies. Medicaid may cover this type of assessment, depending on the caregiver referral question and state. It is best to call the provider performing the assessment and the child’s Medicaid program to determine coverage.

Clinician’s Role
The medical home can support the family in obtaining an assessment by helping them understand their testing options, providing referrals when needed for neuropsychological testing, and advocating for the child’s needs.

The referral process can start with the school, clinician, or family.

School-Initiated Assessments
When a child demonstrates significant struggles with learning, the school is obligated under IDEA to perform testing free of cost and, when indicated, establish an IEP or 504 Plan carried out in the least restrictive environment. Most times, before a school initiates testing, interventions must be put into place and monitored to determine if the child can improve their academic performance with some additional instruction, often referred to as Response to Intervention (RTI). [Morin: 2021] If a child responds to classroom interventions with increased academic performance, a learning disability (i.e., specific learning disability diagnosis) is not suspected, and psychoeducational testing may not occur.

If the child continues to have academic struggles, a psychoeducational assessment (see above for a detailed description) is often initiated by the school internally. Occasionally, private schools may advise families to seek an evaluation externally. In this circumstance, the child’s family can request an evaluation through the local public school district or obtain a referral from the child’s primary care clinician for a neuropsychological evaluation.

Clinician-Initiated Referrals
A clinician may initiate a referral for neuropsychological evaluation testing outside the school system at any time deemed necessary if the assessment needs are more complex (such as for a medically complex child) or if it is the caregiver’s preference. Outside referrals initiated by a clinician typically fall under the umbrella of neuropsychological testing and are insurance-based services. A neuropsychological assessment offers more complex testing beyond what the school can perform and provides a medical diagnosis (e.g., SLD, ADHD) that can be used for special education planning in addition to outpatient programming. A clinician will have to make a determination with the family for the necessity of an outside referral based on their understanding of the child’s history, current and presenting issues, as well as the perception of what treatment service package may best serve the child (e.g., school services, school services + outpatient programming).

Under IDEA, families can request the school to perform a psychoeducational assessment if they have a concern the school has not identified their child’s learning difficulties. In this case, the school can perform the psychoeducational assessment without first utilizing RTI.

With the family’s permission, the primary care clinician can assist the evaluation team by sharing known medical diagnoses or other factors that may influence learning and behavior. These include known or suspected genetic syndromes; teratogen or toxin exposures; neurodevelopmental and psychiatric disorders; language disorder; perinatal history such as prematurity or hypoxic-ischemic injury; brain injury; history of traumatic or adverse events; sensory impairments (e.g., hearing or vision); and insights gleaned through taking comprehensive care of the child. Some common comorbidities with specific learning disabilities can affect the ability of educational interventions to succeed or fail are: [Sahu: 2019]

• Anxiety Disorders & Attention Deficit Hyperactivity Disorder (ADHD)
• Anxiety Disorders
• Depression

Unlike a specific learning disability, these conditions are commonly diagnosed and managed in the primary care setting. More information on screening for common behavioral health conditions can be found at Mental Health Screening for Children & Teens.

Learning Disabilities & ADHD

ADHD and specific learning disabilities are common comorbid conditions. Differentiating between ADHD and a specific learning disability can be challenging:

Thirty-three percent of children with specific learning disabilities also have ADHD. [Margari: 2013] One study noted approximately 31-45% of children with ADHD also have a specific learning disability. [DuPaul: 2013] In a study of children with hard-to-treat ADHD or with ADHD and other comorbid conditions, 50% were found to have a specific learning disability. [Koolwijk: 2014]

However, inattention due to a learning disability is typically due to frustration, lack of interest, or lack of ability that manifests during academic work, unlike ADHD, where inattentiveness persists in multiple domains of life. [American: 2015] Specific learning disabilities can present with symptoms across academic domains, especially when involving language abilities, but should not present in non-academic settings such as mealtimes. Only children with a specific learning disability had significant impairment in verbal updating, whereas children with ADHD, and those with a specific learning disability in comorbidity with ADHD, had the worst performance in visuospatial updating. [Jaycox: 2004]

Overlap and Differences
Caregivers may feel the school is not assisting appropriately during the identification of their child’s learning struggles. Thus, they may depend on a clinician to assist them in identifying a specific learning disability and/or understanding the special education process. As clinicians, supporting parents is an essential role that may involve informing families of advocacy groups that can resolve any disruptions in the process of identifying a learning difficulty. Each state will have its own advocacy group. Clinicians can refer families to advocacy groups if caregivers do not perceive the school is addressing their child’s needs in a way that adequately improves the presenting issues of their child’s academic impairment. Advocacy groups that clinicians can refer caregivers to include:

• Family Voices
• Find Your Parent Center

The essential roles of any clinician working with families who express concern that their children have learning struggles are:

Partnership

• Partner with the family to ensure they are familiar with options available through the educational system to support children with learning disabilities.
• The medical home can offer documentation of pre-existing conditions as well as current diagnoses associated with learning disabilities to the family to share with the school.

Education

• Inform families of conditions that are risk factors for learning difficulties (e.g., prematurity, family history of learning disability, poverty, in utero drug exposure, ADHD, speech delays, phonological difficulties, impairments to fine motor skills, and delayed adaptive abilities) so that families can be aware of these issues and monitor for their child’s potential educational impairment.
• Assist families by providing knowledge of the special education process. Inform families that any subsequent special education planning must follow the rules and regulations set forth by the Individuals with Disabilities Educational Act.
  • See Special Education Laws and Process