Ask the Expert: Learning Disabilities

This question touches upon many important evaluation and treatment issues relevant to learning disorders. Foremost, although this patient’s significant academic difficulties in medical school are of serious concern, you should definitely not advise him about a decision as important as his career aspirations and course of study without a thorough educational diagnostic evaluation.

Dyslexia is defined by the International Dyslexia Association as“a specific learning disability that is neurological in origin. It is characterized by difficulties with accurate and/or fluent word recognition and by poor spelling and decoding abilities… typically result[ing] from a deficit in the phonological component of language that is often unexpected in relation to other cognitive abilities and the provision of effective classroom instruction. Secondary consequences may include problems in reading comprehension and reduced reading experience that can impede the growth of vocabulary and background knowledge” (1). The phonological component of language refers to phonemes; the units of sound in a language that distinguish one word from another (2). There is broad consensus that learning disorders have a neurological basis related to brain maturation and function with a strong genetic component, influenced by external protective and risk factors such as poverty, deprivation, and lack of educational opportunities. Skills for reading utilize a wide, bilateral though heavily left hemispheric network of areas of the brain following activation from occipitotemporal areas through temporal areas toward the frontal and inferior frontal lobes (3).

The term “dyslexia”is not a term used by DSM-IV. It is one type of reading disorder related to the recognition of phonemes, or units of sound, that would be included within the DSM-IV category of reading disorder (315.00) (4). Other reading disorders may relate to comprehension, visual symbol recognition, or orthographical and semantic representations that involve visual, auditory and conceptual processing (3). The term learning disability is also not used by DSM-IV. It is an educational term that has been used in educational and disability legislation such as the Individuals with Disabilities Education Improvement Act (IDEA) (5). The term learning disorder is used by the DSM-IV when “an individual’s achievement on individually administered, standardized tests in reading, mathematics, or written expression are substantially below that expected for age, schooling, and level of intelligence” (4). Individuals with dyslexia usually meet criteria for 315.00 Reading Disorder and often meet criteria for 315.2 Disorder of Written Expression and 315.1 Mathematics Disorder in the Learning Disorders section of Disorders Usually First Diagnosed in Infancy, Childhood, or Adolescence in the DSM IV (4). Those with these disorders do not “grow out of” their disability, and often suffer lifelong disability beyond school age in many realms of adult functioning (4). Early identification and intervention, remediation, and appropriate accommodation have significant impact on outcome. Like this patient, there is a high comorbidity between learning disorders and attention deficit disorders (3, 4, 6). Of those diagnosed with Reading Disorder 60%–80% are male (3).

Individuals diagnosed with reading disorder can be of high intelligence. While their overall achievement can be negatively impacted by their disorder, their intelligence should not be considered equivalent to their disability. This patient’s history suggests that with appropriate intervention and remediation he was able to be highly accomplished in his academic career. His difficulties in medical school may not reflect a ceiling for his potential accomplishment, but rather, his adaptation to a new vocabulary or lexicon, especially coming from a background in the humanities. Unless recently completed he should receive a thorough, individualized diagnostic educational assessment focusing on reading fluency and comprehension as well as writing skills and mathematics. While there are a number of evaluation instruments selectively used by educational diagnosticians depending on the specific presenting problems, his assessment should include tests of intellectual functioning, tests of academic achievement, and specific tests to address the underlying skills involved in reading and writing. These can outline the topography of his vulnerabilities and strengths, leading to the design of potential accommodations.

Appropriate accommodations may include access to printed lectures to avoid note taking that distracts from opportunities for auditory comprehension, access to taped lectures and readings, word processing with the use of spell check, voice recognition software for writing, tutoring to preview and review new vocabulary, reduced course load whenever possible, and, most importantly, untimed or extended time on examinations.

Professional students including medical students with reading disorder and disorder of written expression have been known to perform below the 25th percentile on timed tests but at the 99th percentile on the same material with time accommodation. The latter score is the more accurate gauge of mastery of material and ultimately, of clinical competence. Medical students with learning disorders have become chief residents and, ultimately, competent, well respected and trusted clinicians whose disability is not apparent to colleagues and patients. However, it is possible that even with appropriate accommodation the patient might still be unable to manage the volume, pace and level of medical school studies. If after evaluation and appropriate accommodation he continues to have serious academic difficulties, it may be reasonable to begin to counsel him regarding alternate career plans.