Specific Learning Disability

Overview

A specific learning disability (SLD) is often defined as academic achievement falling below what one would predict given a child's measured intelligence. The Diagnostic and Statistical Manual of Mental Disorders (DSM-5) classifies an SLD as a neurodevelopmental disorder experienced by 5-15% of school-age children. [American: 2013]

While evaluation and intervention for specific learning disabilities (SLDs) primarily occur within the educational system, primary care clinicians need to distinguish underlying conditions that either mimic, contribute to, and/or cause SLDs and help families understand and access diagnosis and management options.
Since SLDs cannot be identified until formal education has started, the definition, assessment, and treatment are significantly influenced by special education law, which defines SLDs as “a disorder in 1 or more of the basic psychological processes involved in understanding or in using language, spoken or written, which disorder may manifest itself in the imperfect ability to listen, think, speak, read, write, spell, or do mathematical calculations.” [U.S.: 2015]

ICD-10 Coding

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

Pearls & Alerts

Diagnosis of SLDs
Primary care clinicians do not diagnose SLDs. Traditionally, SLDs are identified through psychoeducational testing in the school system. Alternatively, neuropsychological testing may be performed privately by a psychologist.

SLDs vs. ADHD
Inattention due to an SLD is typically due to frustration, lack of interest, or lack of ability that manifests during academic work; with ADHD, inattentiveness persists in multiple domains of life.

Clinical Assessment

Unlike developmental delays in infancy and early childhood, primary care clinicians do not perform routine screening for SLDs. As part of routine health supervision, ask if the family or school has any concerns about their school-aged child’s learning. Consistently low performance in one or more subjects should raise suspicion for SLDs. A significant discrepancy in performance in one area could signal the presence of an SLD even in an otherwise high-achieving student. Once a clinician identifies concern, the best evaluation and treatment course, including ruling out differential diagnoses (such as intellectual disability) and managing common, comorbid conditions (e.g., ADHD), is put in place.

Differential Diagnosis of SLDs

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 SLDs. 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 an SLD.

School Assessments and Clinician’s Role

SLDs 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 SLDs:
  • 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 an SLD 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 under-achievement and diagnosis of an SLD. 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 an SLD should not be overly relied on (e.g., discrepancy model). [National: 1994]

Psychoeducational Assessments

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 one or more significant learning impairments, the school and family work together to develop special education learning plans (i.e., IEP) or school accommodations (504 Plan) 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.

Neuropsychological Assessments

A neuropsychological evaluation is a comprehensive assessment that affords a differential diagnosis of SLD, 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.

Referring for Testing

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., SLD) 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).

Family-Initiated Assessments

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.
For more information about special education terminology, see Education & Schools Definitions & Terms.

Management

While the primary care clinician does not diagnose SLDs, the clinician can assist the family and child by partnering with the educational team, advocating for the child, continually monitoring for comorbid conditions, treating as indicated, and ensuring that the family is aware of any additional resources in the community. Once an SLD has been identified, support the child’s learning with evidence-based interventions targeting the specific difficulties of the learning disabilities. These can include tutoring, resource classes, and/or special education, and medications and/or parent training in behavior management for ADHD if present. Children who have been accurately assessed and diagnosed have a greater chance of making good academic progress. Early intervention for SLD is critical for optimal outcomes. Children identified with SLDs may also have a greater sense of efficacy and self-esteem because they better understand their own learning style and are empowered by the educational interventions. [Barkley: 2014]
Partnering with the Educational Team
Two-way communication with the educational team, if authorized by the family, can be helpful in monitoring the child’s progress and assessing for additional needs. In the initial stages of identifying potential learning struggles in children, clinicians may want to review documentation from the child’s history for any medical conditions that may affect learning (e.g., prematurity, existing diagnoses, ADHD). This information should be documented in a way that can be passed along to the school so that collateral information regarding the child’s medical history and current diagnosis can assist in the decision-making process of the school’s special education team as they develop a learning plan. Additionally, medical documentation can be required for certain learning plans (e.g., 504). This letter should be given to the school’s special education director. If the family delivers the letter to the school, no two-way communication release is required. See sample letter below:

Managing Comorbid Medical Conditions

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.
ADHD, anxiety, and depression are common comorbidities with SLDs and can affect the ability of educational interventions to succeed or fail. [Sahu: 2019] Unlike SLDs, 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. More specific guidance on diagnosis and treatment is available at:

SLD and ADHD

ADHD and SLDs are common comorbid conditions. Because differentiating between ADHD and SLDs can be challenging, here is a summary:
Thirty-three percent of children with SLDs also have ADHD. [Margari: 2013] One study noted approximately 31-45% of children with ADHD also have an SLD. [DuPaul: 2013] In a study of children with hard-to-treat ADHD or with ADHD and other comorbid conditions, 50% were found to have an SLD. [Koolwijk: 2014]
However, inattention due to an SLD 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] SLD 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 SLD had significant impairment in verbal updating, whereas children with ADHD, and those with SLD in comorbidity with ADHD, had the worst performance in visuospatial updating. [Jaycox: 2004]
Detailed explanation of the overlap and differences between ADHD and SLD
SLD has many underlying components, including deficits in language, auditory processing, memory/recall, and visual-motor/graphomotor domains. Deficits in these areas may contribute to the presentation of symptoms that are very ADHD-like. For example, a dysfluent reader may be dyslexic rather than distractible. A child who has a memory/recall problem may look inattentive and seem to appear as if they lack focus. The child who appears restless and slow in completing written seatwork/homework may have a bona fide processing speed problem or dysgraphia. A student with an SLD may appear off-task and not focused but is actually struggling to comprehend all the information being presented in the classroom. Notes or assignments may not be accurately written down from the board because of visual-spatial issues rather than poor attention or distractibility. To complicate matters, children with intellect in the gifted range may also have a specific learning disability. [Lovett: 2013]
Parents and teachers often report that effective medication treatment of ADHD results in improved reading fluency and accuracy, handwriting, on-task behavior, and overall “availability” to learn. If the child is putting in good effort and has good educational and parent support but is still struggling academically after ADHD medications are administered, the presence of an SLD should be considered. If there is a family history of SLD, then it is important to assess for the presence of an SLD when first assessing for ADHD.

Advocating for the Child

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 an SLD 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:
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
Referral
  • Know how to help parents reach out to their school or their district’s special education program children for psychoeducational evaluation
  • Refer to neuropsychological testing for complex evaluations that may include SLDs, ADHD, autism, and other neurodevelopmental disorders. See Neuropsychological Assessment (see NM providers [14]).

Resources

Information & Support

The Medical Home Portal's Education & Schools section for clinicians has related information, including School Accommodations: IEPs & 504s. There is also related information for parents about School Types and Options, Special Education Supports and Services, Definitions & Terms Education FAQ, Forms for Education.

For Professionals

A Comprehensive Resource Guide about Learning Disabilities for the Pediatric Professional Community & Parents
Guidance for screening, diagnosing, and supporting children with learning disabilities and their families; from the National Center for Learning Disabilities, the American Academy of Pediatrics, and the National Association of Pediatric Nurse Practitioners.

RTI Action Network: Webinars
A list of training opportunities for educators to develop skills and increase knowledge of effective Response-To-Intervention (RTI) practices. Webinars include the RTI-Based SLD Identification Toolkit. RTI Action Network is a program of the National Center for Learning Disabilities.

For Parents and Patients

Support

National Center for Learning Disabilities
Support, research, scholarships, and advocacy group for individuals with learning disabilities and their families.

Understood for Learning & Attention Issues
An organization providing resources to young adults, parents, and teachers of children with different learning styles and attention disorders. Focusses on inclusive workplaces by developing and implementing best-in-class disability inclusion programs so they can hire, advance, and retain people with disabilities.

General

Learning Disabilities (AAP)
A collection of patient education for families to better understand learning disabilities; HealthyChildren.org.

Parental Rights under IDEA
For the majority of parents, the most relevant procedural safeguards under IDEA are identified on the Center for Parent Information & Resources website. Dated Oct. 5, 2017. Also in Spanish.

IDEA Parent Guide (National Center for Learning Disabilities) (PDF Document 1.1 MB)
A comprehensive guide for parents on rights and responsibilities under the Individuals with Disabilities Education Act (IDEA 2004). Helps parents determine if their child might be eligible for services, what kind of services to expect, how to request an evaluation, how to develop a plan for services, and what their legal rights are. (105 pages, 2014)

Patient Education

Understanding Special Education
This resource answers many frequently asked questions by families about special education rights; Attention.org.

What Is Specific Learning Disorder? (APA)
Diagnosis, treatment, terminology, Expert Q&A, and patient stories related to specific learning disabilities; American Psychological Association.

Tools

Letter to Schools for a Child with a Learning Disability (Word Document 23 KB)
A clinician's letter to for the school with recommendations for learning modifications of a child with SLD; adapted from the Arthritis Foundation.

Services for Patients & Families in New Mexico (NM)

For services not listed above, browse our Services categories or search our database.

* number of provider listings may vary by how states categorize services, whether providers are listed by organization or individual, how services are organized in the state, and other factors; Nationwide (NW) providers are generally limited to web-based services, provider locator services, and organizations that serve children from across the nation.

Authors & Reviewers

Initial publication: August 2021; last update/revision: August 2021
Current Authors and Reviewers:
Author: Sean Cunningham, Ph.D.
Contributing Author: Jennifer Goldman-Luthy, MD, MRP, FAAP
Authoring history
2020: first version: Dorothee Serpas, Ph.D.A
AAuthor; CAContributing Author; SASenior Author; RReviewer

Page Bibliography

American Psychiatric Association.
Diagnostic and Statistical Manual of Mental Disorders, DSM-5.
Fifth ed. Arlington, VA: American Psychiatric Association; 2013. 978-0-89042-554-1

American Psychiatric Association.
Neurodevelopmental Disorders.
American Psychiatric Association; (2015) http://dsm.psychiatryonline.org/doi/full/10.1176/appi.books.9780890425.... Accessed on August 2021.

Barkley R.
Attention-Deficit Hyperactivity Disorder: A Handbook for Diagnosis and Treatment.
Fourth ed. New York: Guilford Press; 2014. 9781462517725

Jaycox LH, Ebener P, Damesek L, Becker K.
Trauma exposure and retention in adolescent substance abuse treatment.
J Trauma Stress. 2004;17(2):113-21. PubMed abstract

Lovett BJ, Sparks RL.
The identification and performance of gifted students with learning disability diagnoses: a quantitative synthesis.
J Learn Disabil. 2013;46(4):304-16. PubMed abstract

Morin A.
Understanding Response to Intervention.
Understood For All Inc.; (2021) https://www.understood.org/en/school-learning/special-services/rti/und.... Accessed on August 2021.

National Joint Committee on Learning Disabilities (NJCLD).
In Collective Perspectives on Issues Affecting Learning Disabilities.
Learning Disabilities Issues on Definition.. 1994; 61-66). Austin: PRO-ED

Sahu A, Patil V, Sagar R, Bhargava R.
Psychiatric Comorbidities in Children with Specific Learning Disorder-Mixed Type: A Cross-sectional Study.
J Neurosci Rural Pract. 2019;10(4):617-622. PubMed abstract / Full Text
This cross-sectional study examined the psychiatric comorbidities among children with SLD.

U.S. Department of Education.
IDEA Title IA602(30).
(2015) https://sites.ed.gov/idea/statuteregulations/. Accessed on August 2021.