In 2013, the DSM-5* changed the diagnostic criteria for Specific Learning Disorder (SLD) to combine all three learning disorders (reading, mathematics, and written expression) into one overarching diagnosis. Specific learning disorders (often referred to as a learning disorder or learning disability, see note on terminology) are neurodevelopmental disorders that are typically diagnosed in early school-aged children, although may not be recognized until adulthood. They are characterized by a persistent impairment in at least one of three major areas: reading, written expression, and/or math.

An estimated 5 to 15% of school-age children struggle with a learning disability.¹ An estimated 80% of those with learning disorders have an impairment in reading in particular (commonly referred to as dyslexia). Dyslexia is common, affecting 20% of the population.² Dyslexia affects males and females equally. Specific learning disorder often occurs along with other neurodevelopmental disorders (such as ADHD) and with anxiety.¹

Specific skills that may be affected include word reading accuracy, spelling, grammar, or calculation. In addition, fluency in reading and mathematics may be noted. Difficulties with these skills often cause problems in learning subjects such as history, math, science and social studies and may impact everyday activities and social interactions.

Learning disorders are categorized as mild, moderate and severe. Accommodation and support services align with the severity to facilitate a person’s most effective functioning.

Learning disorders, if not recognized and managed, can cause problems throughout a person’s life beyond having lower academic achievement. These problems include increased risk of greater psychological distress, poorer overall mental health, unemployment, underemployment and dropping out of school.

A note on terminology: Specific learning disorder is a medical term used for a clinical diagnosis. It is often referred to as “learning disorder.” “Learning disability” is a term used by both the educational and legal systems. Though learning disability is not exactly synonymous with specific learning disorder, someone with a diagnosis of specific learning disorder can expect to meet criteria for a learning disability and have the legal status of a federally recognized disability to qualify for accommodations and services in school. The term “learning difference” is a term that has gained popularity, especially when speaking with children about their difficulties, as it does not label them as “disordered."

To be diagnosed with a specific learning disorder (SLD), a person must meet four criteria.

1. Have difficulties in at least one of the following areas for at least six months despite targeted help:
   • Difficulty reading (e.g., inaccurate, slow and only with much effort).
   • Difficulty understanding the meaning of what is read.
   • Difficulty with spelling.
   • Difficulty with written expression (e.g., problems with grammar, punctuation or organization).
   • Difficulty understanding number concepts, number facts or calculation.
   • Difficulty with mathematical reasoning (e.g., applying math concepts or solving math problems).
2. Have academic skills that are substantially below what is expected for the child’s age and cause problems in school, work or everyday activities.
   • This criterion requires  academic skill challenges to be based on standardized achievement measures and “comprehensive clinical assessment.”
3. The difficulties start during school-age even if some people don’t experience significant problems until adulthood (when academic, work and day-to-day demands are greater).
4. Learning difficulties are not due to other conditions, such as intellectual disability, vision or hearing problems, a neurological condition (e.g., pediatric stroke), adverse conditions such as economic or environmental disadvantage, lack of instruction, or difficulties speaking/understanding the language.

A diagnosis is made through a combination of observation, interviews, family history and school reports. Neuropsychological testing may be used to help find the best way to help the individual with specific learning disorder. For individuals over age 17, a documented history of learning impairment may be substituted for the standardized assessment.

The merging of three separate learning disorders into one diagnostic category under Specific Learning Disorder (SLD) in the DSM-5 required three different specifiers to identify the area(s) of academic weakness:

1. With impairment in reading (dyslexia)
2. With impairment in written expression (dysgraphia)
3. With impairment in mathematics (dyscalculia)

Dyslexia

The specifier “with impairment in reading” is added to the SLD diagnosis when a person demonstrates significant impairment in one or more of the reading subskills including word reading accuracy, reading rate or fluency, and/or reading comprehension. Dyslexia may be used as an alternative term that refers to problems with word reading fluency or word reading accuracy, decoding, and spelling.

Problems in reading may begin even before learning to read. For example, children with dyslexia may have trouble with breaking down spoken words into syllables andor recognizing words that rhyme. People with dyslexia often have difficulty connecting letters they see on a page with the sounds they make. As a result, reading becomes slow and effortful and is not a fluent process for them. People with dyslexia may also have difficulty with writing accuracy and spelling.

Adolescents and adults with dyslexia often try to avoid activities that involve reading when they can (reading for pleasure, reading instructions). They often gravitate to other media such as pictures, video, or audio.

Dysgraphia

An impairment in writing skills is assigned to the specifier “with impairment in written expression” and refers to those children with impaired spelling and problems with writing that can include difficulties with accuracy, grammar, and punctuation accuracy, and/or clarity or organization of written expression. Problems in reading begin even before learning to read. For example, children may have trouble breaking down spoken words into syllables and recognizing words that rhyme. Dysgraphia is the term used to describe difficulties with putting one’s thoughts on to paper. Kindergarten-age children with impairment in written expression may not be able to recognize and write letters as well as their peers.

Dyscalculia

The third SLD specifier “with impairment in mathematics” is for individuals who demonstrate significantly below average skills in number sense, memorization of arithmetic facts, accurate or fluent calculation, and/or accurate math reasoning. The term “dyscalculia” is used to describe difficulties with learning number number-related concepts, with processing numerical information, with learning arithmetic facts or with using the symbols and functions to perform accurate or fluent math calculations. 

Severity Levels

In addition to specifying the domain of learning disorder, the degree of severity should also be indicated in the SLD diagnosis. There are three levels of SLD severity.

• Mild: Some difficulties with learning in one or two academic areas, but may be able to compensate with appropriate accommodations or support services.
• Moderate: Significant difficulties with learning, requiring some specialized teaching and some accommodations or supportive services may be needed in school, in the workplace, or at home for activities to be completed accurately and efficiently.
• Severe: Severe difficulties with learning, affecting several academic areas and requiring ongoing intensive specialized teaching for most of the school years. Even with accommodations, an individual with a severe SLD may not be able to perform academic tasks with efficiency.

Though there is no “cure,” specific learning disorders can be successfully managed throughout one’s life. People with specific learning disorders can go on to become skilled learners and may be able to build on strengths that often are associated with their learning differences. People with dyslexia, for example, are often particularly creative and able to think outside-of-the-box.

Having a learning disorder does not mean a person is limited in their choice of career or the opportunities for success. Early intervention is key for people with a SLD. If problems are identified early, intervention can be more effective, and children can avoid going through extended problems with schoolwork and possible challenges with self-esteem.

Under federal law, per the Individuals with Disabilities Education Act (IDEA), students with learning disorders are eligible for special education services. The law requires that if a child is suspected of having a specific learning disability, the school must provide an evaluation. Those found to have specific learning disorders are eligible for special education services. An IEP team, including school personnel and parents, will develop an Individualized Education Plan (IEP) for the student with SLD. Parents should specifically ask for an evaluation if they are concerned. Educational advocates may be helpful to families in the IEP process. The federal law also requires that free appropriate public education (FAPE) be offered to all students, including those requiring special education.

Special education services can help children with learning disabilities improve in their reading, writing and math skills. Effective interventions involve systematic, intensive and individualized instruction that may improve the learning difficulties and/or help the individual use strategies to compensate for their disorder. 

Currently, there are no FDA approved medications for specific learning disorders. However, medications may be prescribed for co-occurring disorders such as ADHD and anxiety. Research has shown that the most effective treatments for SLD with impairment in reading are structured and targeted strategies that address phonological awareness, decoding skills, comprehension and fluency. Treatments for writing problems are in two general areas: the process of writing and the process of composing written expression. Treatment for dyscalculia often includes multisensory instruction to help kids understand math concepts. Accommodations, like using manipulative and assistive technology, may also help kids with dyscalculia.

Students with specific learning disorders often benefit from other school accommodations, such as additional time for tests and written assignments, using computers for typing rather than writing by hand, and smaller class sizes. Successful interventions, strategies and accommodations for a child may change over time as the child develops and academic expectations change.

*Diagnostic and Statistical Manual of Mental Disorders, 5th Edition, Text Revision. American Psychiatric Association, 2022.

  References

Physician Review

Rubí E. Luna, M.D.
UCLA Semel Institute for Neuroscience and Human Behavior
Child and Adolescent Psychiatry Fellow, PGY-5
Member, APA Council on Communications

March 2024