Psychopathology
Specific Learning Disorders

Table of contents
Index Pages
Introduction 3
Diagnostic criteria 4
Aetiology 11
Differential diagnosis 14
Comorbodity 16
Prevalence 16
Prevention and Treatment 17
Prognosis 18
Multicultural factors 19
Social factors 19
Conclusion 20
References 21

Stupid
Slow
Stubborn
A tiny fragment of words used, labels for children and people with specific learning disorders. If only they understood
Introduction
The most basic definition of a specific learning disorder/disability according to Gould (2005) cited in Rörich (2008) is when a learner has an average to above average intelligence, with normal vision and hearing, and receives the same teaching experiences as other learners his age. He, however, underachieves. He is unable to keep up with his peers and generally cannot cope with the demands of the school (pp16).
Margari (2013) defines SLD’s as that which are characterizations of academic functioning that are below the level that would be expected given their age, Intelligent Quotient and grade level in school, and interfere significantly with academic performances or daily life activities that require reading, writing or calculation skills.
The gist of it, is that specific learning disorders are neurodevelopmental/cognitive disorders that Hulme and Snowling (2009,pp22) define as “typically characterized by slow rates of development, either in specific domain (specific learning disabilities such as dyslexia or mathematics disorder) or more generally across many domains (general learning difficulties or mental retardation).
Finally, Rorich (2008, pp16) explains that the South African contexts defines these, as barriers to learning or learning disabilities in which then a "Specific learning disability", is a disorder in one or more of the basic psychological processes involved in understanding or in using language, spoken or written, that may manifest itself in an imperfect ability to listen, think, speak, read, write, spell or to do mathematical calculations.
The disorder is identified as a “discrepancy of more than two standard deviations between levels of achievement and intelligence” (Kearney, 2010,pp77).
Specific learning disorders is encapsulated in the DSM 5 as an umbrella term of neurodevelopmental learning disorders that negatively affect the “normal” acquisition of academic skills. These skills were previously categorized separately as reading, writing and mathematics disorders, respectively.
Diagnostic Criteria
The clinical description of Specific according to the DSM 5 (American Psychiatric Association, 2013, 66-74) is explained as:
A. Difficulties learning and using academic skills, as indicated by the presence of at least one of the following symptoms that have persisted for at least 6 months, despite the provision of interventions that target those difficulties:
1. Inaccurate or slow and effortful word reading (e.g., reads single words aloud incorrectly or slowly and hesitantly, frequently guesses words, has difficulty sounding out words).
2. Difficulty understanding the meaning of what is read (e.g., may read text accurately but not understand the sequence, relationships, inferences, or deeper meanings of what is read).
3. Difficulties with spelling (e.g., may add, omit, or substitute vowels or consonants).
4. Difficulties with written expression (e.g., makes multiple grammatical or punctua­tion errors within sentences; employs poor paragraph organization; written expression of ideas lacks clarity).
5. Difficulties mastering number sense, number facts, or calculation (e.g., has poor understanding of numbers, their magnitude, and relationships; counts on fingers to add single-digit numbers instead of recalling the math fact as peers do; gets lost in the midst of arithmetic computation and may switch procedures).
6. Difficulties with mathematical reasoning (e.g., has severe difficulty applying mathematical concepts, facts, or procedures to solve quantitative problems).
B. The affected academic skills are substantially and quantifiably below those expected for the individual’s chronological age, and cause significant interference with academic or occupational performance, or with activities of daily living, as confirmed by individually administered standardized achievement measures and comprehensive clinical assessment. For individuals age 17 years and older, a documented history of impairing learning difficulties may be substituted for the standardized assessment.
C. The learning difficulties begin during school-age years but may not become fully manifest until the demands for those affected academic skills exceed the individual’s limited capacities (e.g., as in timed tests, reading or writing lengthy complex reports for a tight deadline, excessively heavy academic loads).
D. The learning difficulties are not better accounted for by intellectual disabilities, uncorrected visual or auditory acuity, other mental or neurological disorders, psychosocial adversity, lack of proficiency in the language of academic instruction, or inadequate educational instruction.
Note; The four diagnostic criteria are to be met based on a clinical synthesis of the individual’s history (developmental, medical, family, educational), school reports, and psycho-educational assessment.
Coding note: Specify all academic domains and subskills that are impaired. When more than one domain is impaired, each one should be coded individually according to the following specifiers.
Specify if:
With impairment in reading:
Word reading accuracy
Reading rate or fluency
Reading comprehension
Note: Dyslexia is an alternative term used to refer to a pattern of learning difficulties characterized by problems with accurate or fluent word recognition, poor decoding, and poor spelling abilities. If dyslexia is used to specify this particular pattern of difficulties, it is important also to specify any additional difficulties that are present, such as difficulties with reading comprehension or math reasoning.
With impairment in written expression:
Spelling accuracy
Grammar and punctuation accuracy
Clarity or organization of written expression
With impairment in mathematics:
Number sense
Memorization of arithmetic facts
Accurate or fluent calculation
Accurate math reasoning
Note: Dyscalculia is an alternative term used to refer to a pattern of difficulties characterized by problems processing numerical information, learning arithmetic facts and performing accurate or fluent calculations. If dyscalculia is used to specify this particular pattern of mathematic difficulties, it is important also to specify any additional difficulties that are present, such as difficulties with math reasoning or word reasoning accuracy.
Specify current severity:
Some difficulties learning skills in one or two academic domains, but of mild enough severity that the individual may be able to compensate or function well when provided with appropriate accommodations or support services, especially during the school years.
Moderate: Marked difficulties learning skills in one or more academic domains, so that the individual is unlikely to become proficient without some intervals of intensive and specialized teaching during the school years. Some accommodations or supportive services at least part of the day at school, in the workplace, or at home may be needed to complete activities accurately and efficiently.
Severe: Severe difficulties learning skills, affecting several academic domains, so that the individual is unlikely to learn those skills without ongoing intensive individualized and specialized teaching for most of the school years. Even with an array of appropriate accommodations or services at home, at school, or in the workplace, the individual may not be able to complete all activities efficiently
Before a diagnosis is made in the case of specific learning disorders, it is the clinician’s responsibility to rule out all other factors that may contribute to the poor academic functioning. Kearney (2010) presented a case study in which the client, an 8 year old Hispanic girl, named presented poor achievement scores despite having a “normal” intelligence as described. In the case of Gisele, she was referred to a different school during the course of the year, she was being in taught in a second language and she never failed although she performed badly especially in tasks that required reading and writing.(pp75-77).
With regards to the brief case presented, in ruling out other possible factors to the poor academic functioning. The clinical psychologist, is expected to consider the home language of the client and whether the client perhaps cannot communicate in the language of teaching which is English. Secondly, the impact of being in different school environment may present adjustment issues, possible trauma and the client may perhaps be in need of time to adapt to the teaching style of the educator. A classic example if it were true, is presented in the parents of Gisele, Mr. and Mrs Garcia that ended up blaming the school instead for poor teaching practices and also then claiming that she had come from a “poorly funded school in general” (Kearney, 2010, pp77-78). This demonstrates that in specific learning disorders, the institution of learning matters, socio-economic factors may also contribute learning problems, as well as other biological factors such as deafness or being blind.
It is evident that a thorough clinical assessment must always be administered before diagnosing any client, with regards to the case of Gisele, examples of how a comprehensive clinical assessment is administered, will follow (Burke,2014,pp35-46): * Clinical interview: family history, history of client’s life, detailed description of presenting problem, information on attitudes, emotions and current/past behaviour as well as information on significant events of the client
According to Kearney (2010) environmental variables such as socio-cultural factors must be considered, which could affect a child’s school-based motivation, competiveness, attitudes and overall school achievement orientation, language deficits were argued by the author to also having the potential to predispose the child to social withdrawal that inhibits other forms of learning . Gisele was reported to have had being a bright student in her early years, also in her previous school she performed well in maths and science, achieving 88 in maths but had now dropped scores because the teacher “often taught maths and science using story problems, creative lab projects that involved reading and writing. Gisele, excelled in mathematics however she was not as strong in reading or writing. This goes back to the DSM 5 note, that suggest that specifications should be made in terms of specific learning disorders. Gisele may be able to solve mathematics calculations but having specific learning disorder with specifications in reading and writing.
Mental Status Examination: Critical analysis on intellectual functioning and thought processes
In addition, Gisele had an obvious misconfigured thought process, unlike other children she was unable to identify, recognise and integrate words and meanings. Gisele “had trouble identifying new and different words, even those in word groups such as law, paw and saw…she had trouble identifying letters of the alphabet” (Kearney, 2010. Pp76).
According to Jean Piaget’s theory of cognitive development, children Gisele’s age should have already mastered a phenomena called symbolic function from the ages of two to four years old, in which the child uses “symbols such as words, images and gestures to represent objects and events mentally” (Guavain and Parke, 2009,pp284). This would require the liquid recognition and identification of letters and words. Symbolic function exists within the preoperational period, whereby the “ability to use symbolic facilitates the learning of language” (Guavain and Parke, 2009, pp284). * Behavioural Assessment:
Gisele’s teacher complained that she was fidgety, inattentive but was not defiant, impolite, overactive etc. She however would make excuses for not completing her homework always suggesting that she had lost her homework. Gisele was observed as being disorganized, her study table was cluttered without any systematic way of doing things. (Kearney, 2010, pp76) * Medical Assessment: neuroimaging, physical examination
Although there was no medical assessment administered in Gisele’s case, neuroimaging would generally focus on the parietal and temporal lobes as they are the ones responsible for sensory integration, speech and language respectively (Weiten, 2010). In brain imaging, the Functional Magnetic Resonance Imaging (FMRI) scans provide “better images of the brain than CT scans” (Vythillingam, 2005 cited in Weiten, 2010, pp95). FMRI monitor blood flow and oxygen consumption in the brain to identify areas of high activity. In specific learning disorders, the scans will monitor the high oxygen activity level within the temporal-parietal region, as this will determine if energy is being used up in the form of sensory-motor integration. According to Kearney (2010) in dyslexia, a reading impairment, the temporal area showed less activity level as compared with people without dyslexia. Therefore, the normal information processing by neurons in the brain was either not present or limited. * Psychological Tests: Intelligence testing, Personality inventories, Projective and
Neuropsychological tests
Mr.Dartil, Gisele’s psychologist administered the Wechsler Intelligence scale for Children in which cognitive functioning is the central focus when assessing children. Gisele received an IQ score of 104 which suggests that she had an average intellectual quotient potential but had achieved below the norms. According to the clinician, Gisele was not “performing to her potential” (pp78).
Aetiology
According the Special Education Services: A Manual of Policies, Procedures and Guidelines (2006) cited in the paper presented by the British Columbia Association of School Psychologists (2007) that learning disorders are a result of genetic and/or neurobiological factors or injury that alters brain functioning in a manner which affects one or more processes related to learning. These disorders then are not due primarily to hearing and/or vision problems, socio-economic factors, cultural or linguistic differences, lack of motivation or ineffective teaching, although these factors may further complicate the challenges faced by individuals with learning disabilities. Learning disabilities may co-exist with various conditions including attention, behaviour and emotional disorders, sensory impairments or other medical conditions (pp.4)
In genetics, according to Mash and Wolfe (2013) children who lacked skills required for reading, such as hearing separate sounds of words, were more likely to have a parent with a related problem (pp372). The authors, Hawke, Wadsworth and Defries (2006) cited Kearney (2010) indicate that twin data revealed that reading disorders had a moderate to strong genetic influence, with chromosomes 1,2,3,6,11,13,15 and 18 were that were affected, which is in agreement with the findings of Gigorenko (2007) which identified that chromosome number 6 was predisposed children to a reading disorder. Though reading disorder in the new DSM 5 is referred to as a specific learning disorder with a reading impairment. Writing and mathematics disorder are not researched as much the reading disorder, as some researchers have suggested that a reading impairment is the root of all learning impairments. A reading impairment is called dyslexia. Dyslexia is defined by Reid (2009) as a processing difference, often characterized by difficulties in literacy acquisition affecting reading, writing and spelling. It can also have an impact on cognitive processes such as memory, speed of processing, time management, co-ordination and automaticity. There may be visual and/or phonological difficulties and there are usually some discrepancies in educational performances (pp4).

The neurological organic dysfunction, not only involves faults in the genetic makeup and chromosomes but also impediments in the certain structures of the brain. The brain, apart from the cerebrum and cerebellum, it is made of up four main functional lobes. Of the four lobes, the temporal and parietal lobes are involved in specific learning disorders. The temporal lobe “contains an area devoted to the auditory processing, called the primary core” (Weiten, 2011, pp103). According to Weiten (2011, pp102) damage to this part of the brain can result in impairments in the comprehension of speech and language. According to Pennington (1991,pp199) a problem in learning phonological labels could easily result from the left temporal lobe structural and functional anomalies.
In addition, another part of the brain that has a part to play in specific learning disorders, is the parietal lobe, which is “involved in integrating visual input and in monitoring the body’s position space” (Weiten, 2011, p102). Not only does the individual with a specific learning disorder fail to integrate what is seen, let’s say on the school board, but they are unable to perceive size and space, and so may write above lines, or misunderstand size and position. The primary visual cortex is not involved though it involves sight, because the reality of specific learning disorders is not the inability to see but to integrate and make sense of visual information.
Therefore the inability of the temporal-parietal lobe to process sensory input from sensory neurons, integrate the information and provide feedback through the motor neurons, results poor performance in reflection of information. In addition, according to Mash and Wolfe, the visual cortex plays a role in specific learning disorders. According to the authors, studies discovered that adults with reading disorders showed no activation in visual motion when asked to view randomly moving dots (pp374). This means that there was no response by the visual regions of these adults, who were not sensitive to the recognition of objects and would show notable defects in perception.
Persons with learning disorders have their short term and long-term memory affected hence they are unable to recall sensations to certain sounds and words, secondly, “language difficulties for people with reading disorders are specifically associated with the neurological processing of phonology and storage of such information into memory and behavioural and physiological abnormalities are found in processing of visual information” (Mash and Wolfe, 2013, pp374). Kearney (2010) found that cognitive deficits in learning disorders include perceptual problem such as distinguishing letters and words as well as linguistic processing problems.
In the left hemisphere of the brain responsible for language, the following segments of the brain are inactive in people with learning disorders: * Primary auditory cortex: responsible for electrical signals from receptors into sounds an sanctions of vowels and consonants * Auditory association area: responsible for basic sensory information from sounds and noises into recognisable patterns of words or music
(Mash and Wolfe, 2011, pp373)
Research suggests that these abnormalities can be detected at the earliest, in the prenatal stage of a foetus, whereby normal cell differentiation doesn’t take place in which each cell carries specific instruction and a memory for their task in the human body. Furthermore, apart from focus on neurological and developmental disabilities that impair functioning, Mash and Wolfe state that foetal alcohol syndrome, insulin-dependent diabetes, autism, irradiation and several other childhood diseases and trauma have been linked to nonverbal learning disorders.
Differential Diagnosis
Specific Learning Disorder and Attention Deficit/Hyperactivity Disorder
In ADHD poor academic achievement cannot be attributed to the inability to fulfil either of the academic skills such as reading, writing or mathematics due to defects in information processing. Rather poor academic achievement is a result of the inability to focus or be attentive to the school due to hyperactivity. Further inattention in specific learning disorders may be due to frustration from not being able to integrate, understand and meet the requirements of the work. Children/Individuals with ADHD may have normal sensory-motor processes and an average or above IQ score. There is a high correlation of SLD’s and ADHD in children, usually overlapping 30%-70% of the time (Mash and Wolfe, 2013).
Specific Leaning Disorder and Intellectual Disability
In Intellectual Disability, poor academic achievement is the result of “deficits in intellectual functions such as reasons, problem solving, planning, abstract thinking, judgement, academic learning, and learning from experience, confirmed by both clinical assessment and individualized, standardized intelligence testing” (APA, 2013, pp33). In specific learning disorder the individual may have an average or above average IQ score but still not be able to process and integrate information, on the other end, in intellectual disability the individuals possess an IQ score that is the expected for school requirements. The similarities entail the inability to conceptualize symbols and concepts. In both, there is a deficit in identification, integration and recognition of words, symbols. Both disorders satisfy the criteria A and B of specific learning disorders, but intellectual disability is ruled out in criteria C, which states that the individual may have SLD in the absence of an intellectual disability. The IQ score of intellectual disability is from 75 and below, whereas children/people with SLD’s may have an average to above average IQ.
Dementia
In dementia, the inability to perform familiar tasks such as writing or reading and understanding what is read or mathematical, is a result of cognitive deterioration in the parts of the brain necessary for execution of sensory-motor functions.. The affected parts of brain lead to a cognitive breakdown. In Specific learning Disorders, the individual develops as a child with Specific learning disorder, in the latter, dementia develops over time (usually thought to be for only older people). The inability to carry out academic functions, is a result of cognitive deterioration that may be well inherited. People with dementia lose the memory capacity to executing tasks such as writing, whereas in SLD’s the individuals are born with this deficit from childhood. Dementia can be understood as a set of multiple cognitive developmental impairments that affect the human memory and cause loss of executive functioning (Baiyewu, Jeste, Reiger, Sirovatka and Sunderland (2007).
Developmental Coordination Disorder
In specific learning disorder the individual is unable to fulfil the writing aspect of academic skills due to not being able to recognize, interpret or integrate the words or symbols. However in DCD, failure to write is due to a low acquisition and execution of the motor skills that then affect academic/school productivity. The fine and gross motor skills attributed to gripping and handwriting are impaired. Kearney (2010) found that children with writing and spelling difficulties also have trouble producing letters, organizing finger movements, mapping out written words phonologically, and integrating visual-motor stimuli.
Learning difficulties
Specific learning disorder is not the result of injury to neurological and sensory organs. Challenges in the sensory organs may include visual and hearing impairments, at other times traumatic brain injury may affect parts of the brain associated with sensory-integration and processing.
Comorbidity
Results from a quantitative study in the article, Neuropsychopathological comorbidities in learning disorders found that in terms of Specific Learning Disorders “ADHD was present in 33%, Anxiety Disorder in 28.8%, Developmental Coordination Disorder in 17.8%, Language Disorder in 11% and Mood Disorder in 9.4% of patients.”(Margari,2013). Kearney (2010) found that learning disorders and attention deficit disorder co-occur in many cases (25%-80%) suggesting that causes overlap (pp81).
Further according to research, 20% of children with SLD have associated ADHD as comorbidity and vice versa. In addition intellectual disabilities and Specific Learning disorders are strongly associated.
Prevalence
The prevalence among adults is argued to be approximately 4% although information is scarce, in school-going children it ranges from 5%-15% (APA, 2013:pp70). As a result of the disorder being genetic, “the familial risk is therefore a useful indicator of dyslexia and is supported by prevalence rates” (Molfese, 2008 cited in Reid, 2009, pp15)

Prevention and Treatment
Mash and Wolfe (2013) believe that training children in phonological awareness activities at an early age may prevent subsequent reading problems among children at risk (pp375). The sooner the identification of learning challenges, the better it is for the child to get remediated. Children with specific learning disorders may need to use alternative methods to conventional teaching strategies employed by the school curriculum. Teachers may need to focus on building on the others strengths of the child such as art, music, drama, role-play and sports to teach.
Treatment typically requires efforts of a multidisciplinary that is inclusive of parents, teachers, peers and psychologists. By means of both cognitive behavioural therapy and psycho-education, a child’s attitude towards learning can be improved through support and investing in alternative methods of teaching.
According to Sams (2006) cited in Azam (2012) the identification of behaviours and feelings is linked to verbal ability and the identification of thoughts is associated with general IQ, thoughts, feelings, and behaviours that are more likely to be understood and correctly identified by people with higher verbal ability and IQ . Therefore for mild specific learning disorder not coupled with intellectual disability, CBT has been found to “help at least part of this population stabilise their mood, resume a more normal life, and engage in society in productive ways” (Azam, 2012.pp17).
While much focus has been on the individuals diagnosed with learning disorders, an institutional framework that will move towards improving mental health services in schools should be considers. Infact, Cowan and Rossen (2014) suggest a multitiered system of supports (MTSS), a framework that is rooted on the basis of providing a continuum of the delivery of services, integrated within a learning environment. These tiers are made up of three goals (Cowen and Rossen, 2014, pp10-11)
Goal 1: Universal wellness promotion and prevention
This goal focuses on promoting positive behaviour and safety, resilience and developing a supportive school environment whereby all students are valued and respected, while those are at risk for mental health problems are identified. The aim is to instil effective primary intervention through screening processes, skills development for both learners/students and staff.
Goal 2: Targeted prevention and intervention
Focus is on the identified problem at classroom level and even in the school. at this level, it is the responsibility of the mental health professionals to assess and guide interventions in collaboration with teachers.
Goal 3: Individual/Tertiary intervention
At this level both direct and indirect mental health services are provided such as counselling. The schools’ employed mental health professionals are required to coordinate with external clinicians and community agencies for intensive clinical service.
Above everything, awareness in schools could be helpful in reducing the effects of stigma and bullying learners/students.
Prognosis
Specific learning disorder with a specific impairment is usually diagnosed during the school going ages. That is usually when the symptoms are highlighted and easily identifiable, once the individual is required to meet academic outcomes and is unable to satisfy the demands. The disorder usually carries out throughout highschool, however given that remedial and psycho-education intervention is provided; students may be able to cope in learning environments, through “developing appropriate strategies for problem-solving and self-control in children” (Jena, 2013,pp123-124).
Multicultural factors
In a country like South Africa, where there are 12 official languages and where technology is not as evolved as in the States, prevalence rates are difficult to determine, but also identifying children with specific learning disorders is problematic. Firstly, in schools where English is still the medium of instruction, children may be either misdiagnosed for specific learning disorders whereas they are not English fluent. Vice versa, the scholar could be perceived as slow to understand English, whereas they have a learning disorder. Secondly, because technology is not as advanced in Africa, diagnosis is delayed, further delaying treatment. Thirdly, one should consider if all schools in South Africa have mental helath professionals particularly, school psychologists. School psychologists “can be particularly good resource to help identify assessment tools and collect, analyse, and interpret”( Cowen and Rossen, 2014, pp12)
Lastly, in intervention, understanding the cultural attitudes and persona experiences of families towards mental health is critical for family engagement as a resource (Cowen and Rossen, 2014).
Social factors
In South Africa, where poverty is rife, as according to Statistics SA (2014) owing to 10, 2 million people living beyond the food line. It is clear every child is offered the opportunity to go to school where specific learning disorders are highlighted as learners struggle to come to grips with the academic requirements. In addition, Foy and Perrin cited in Cowen and Rossen (2014) argue that in many communities, especially rural areas, school still remain the only source of mental health supports for children. Furthermore, an estimated 70% of all learners who receive mental health support, initially receive this at school (pp9).
Conclusion
Specific learning disorders are chronic conditions that cannot be “cured” because of its genetic origins. Specific learning disorders are different from what the school system regards as learning disabilities. Learning disabilities include mental, physical and social challenges that pose as a barrier to learning.
To determine a disorder in learner, standardized psychometric tools should be used in conjunction with reports from the family and educators. However through effective intervention involving remedial classes and alternative forms of teaching by educators, children may thrive and reach their full potential. Like any individual social support remains the most contribute factor in building esteem and the courage to confront one’s own challenges.

References
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