Figure 1. What are the pros and cons of labeling a child with a learning disability?

Children’s cognitive and social skills are evaluated as they enter and progress through school. Sometimes this evaluation indicates that a child needs special assistance with language or in learning how to interact with others. Evaluation and diagnosis of a child can be the first step in helping to provide that child with the type of instruction and resources needed. But diagnosis and labeling also have social implications. It is important to consider that children can be misdiagnosed and that once a child has received a diagnostic label, the child, teachers and family members may tend to interpret actions of the child through that label. The label can also influence the child’s self-concept. Consider, for example, a child who is misdiagnosed as learning disabled. That child may expect to have difficulties in school, lack confidence, and out of these expectations, have trouble indeed. This self-fulfilling prophecy, or tendency to act in such a way as to make what you predict will happen, comes true, and calls our attention to the power that labels can have whether or not they are accurately applied.

It is also important to consider that children’s difficulties can change over time; a child who has problems in school may improve later or may live under circumstances as an adult where the problem (such as a delay in math skills or reading skills) is no longer relevant. That person, however, will still have a label as learning disabled. It should be recognized that the distinction between abnormal and normal behavior is not always clear; some abnormal behavior in children is fairly common. Misdiagnosis may be more of a concern when evaluating learning difficulties than in cases of autism spectrum disorder where unusual behaviors are clear and consistent.

Keeping these cautionary considerations in mind, let’s turn our attention to some developmental and learning difficulties.

Autism Spectrum Disorders

Autism spectrum disorder (ASD) is a developmental disorder that affects communication and behavior. The estimate published by the Center for Disease Control (2018) is that about 1 out of every 54 children in the United States has been diagnosed with Autism Spectrum Disorder (ASD), which covers a wide variety of ranges in ability, from those with milder forms (formerly known as Asperger’s Syndrome) to more severe deficits in communication.^[1]

A person with autism often has difficulty with language. An autistic child may respond to a question by repeating the question or might rarely speak. Sometimes autistic children learn more difficult words before simple words or can complete complicated tasks before they are able to complete easier ones. A child with ASD may have difficulty reading social cues such as the meanings of non-verbal gestures such as a wave of the hand or the emotion associated with a frown. Intense sensitivity to touch or visual stimulation may also be experienced. They often have poor social skills and are often unable to communicate with others or empathize with others emotionally. People with autism often view the world differently and learn differently than people who do not have an autism spectrum disorder. Children with autism tend to prefer routines and patterns and become upset when routines are altered. For example, moving the furniture or changing the daily schedule can be very upsetting.

Many children with ASD are not identified until they reach school age, although the ability to diagnose children earlier continues to improve. In the 2017-2018 school year, about 710,000 children on the spectrum received special education through public schools.^[2] These disorders are found in all racial and ethnic groups and have been thought to be more common in boys than in girls, though new research is evolving^[3]. All of these disorders are marked by difficulty in social interactions, problems in various areas of communication, and in difficulty with altering patterns or daily routines. There is no single cause of ASD and the causes of these disorders are to a large extent, unknown. In cases involving identical twins, if one twin has autism, the other also has ASD about 75 percent of the time. Rubella, fragile X syndrome and PKU that has been untreated are some of the medical conditions associated with the risks of autism.

Some individuals benefit from medications that alleviate some of the symptoms of ASD, but the most effective treatments involve behavioral intervention and teaching techniques used to promote the development of language and social skills. Children also excel when they are in structured learning environments that accommodate the needs of children on the spectrum.

Learning Disabilities

What is a learning disability? If a child has an intellectual disability, or intellectual development disorder, they will have significant impairment in intellectual and adaptive functioning, generally defined by an IQ under 70 (two standard deviations below the median), in addition to deficits in two or more adaptive behaviors that affect everyday, general living. A child with intellectual development disorder typically learns slowly in all areas of learning.

However, a child with a learning disability has problems in a specific area or with a specific task or type of activity related to education. It should be pointed out that learning disabilities are not the same thing as intellectual disabilities. Learning disabilities are considered specific neurological impairments rather than global intellectual or developmental disabilities. These are identified in the Diagnostic and Statistics Manual of Mental Disorders, Fifth Edition (DSM-5) as a specific learning disorder.  A learning difficulty refers to a deficit in a child’s ability to perform an expected academic skill (Berger, 2005). These difficulties are identified in school because this is when children’s academic abilities are being tested, compared, and measured. Consequently, once academic testing is no longer essential in that person’s life (as when they are working rather than going to school) these disabilities may no longer be noticed or relevant, depending on the person’s job and the extent of the disability.

Dyslexia

Dyslexia, sometimes called reading disorder, is the most common learning disability; of all students with specific learning disabilities, 70–80% have deficits in reading. It is characterized by difficulties with accurate and/or fluent word recognition and by poor spelling and decoding abilities. The term developmental dyslexia is often used as a catch-all term, but researchers assert that dyslexia is just one of several types of reading disabilities. A reading disability can affect any part of the reading process, including word recognition, word decoding, reading speed, prosody (oral reading with expression), and reading comprehension. For example, a child may reverse letters, may have difficulty reading from left to right, or may have problems associating letters with sounds. Dyslexia appears to be rooted in some neurological problems involving the parts of the brain active in recognizing letters, verbally responding, or being able to manipulate sounds (National Institute of Neurological Disorders and Stroke, 2006). Treatment typically involves altering teaching methods to accommodate the person’s particular problematic area.

Dyscalculia

Dyscalculia is a form of math-related disability that involves difficulties with learning math-related concepts (such as quantity, place value, and time), memorizing math-related facts, organizing numbers, and understanding how problems are organized on the page. People with this dyscalculia are often referred to as having poor “number sense.”

Dysgraphia

The term dysgraphia is often used as an overarching term for all disorders of written expression. Individuals with dysgraphia typically show multiple writing-related deficiencies, such as grammatical and punctuation errors within sentences, poor paragraph organization, multiple spelling errors, and excessively poor penmanship.

Attention Deficit Hyperactivity Disorder (ADHD) is considered a neurological and behavioral disorder in which a person has difficulty staying on task, screening out distractions, and inhibiting behavioral outbursts. The most commonly recommended treatment involves the use of medication, structuring the classroom environment to keep distractions at a minimum, tutoring, and teaching parents how to set limits and encourage age-appropriate behavior (NINDS, 2006). Some people say that the term Attention Deficit is a misnomer because people who suffer from ADHD actually have great difficulty tuning things out. They are bombarded with information… their brains are trying to pay attention to everything. They do not have a deficit of attention- they are trying to pay attention to too many things at once, so everything suffers.

Recent research suggests that several brain structures may be implicated in ADHD. These studies have mainly focused on the frontal lobe and prefrontal cortex.^[4] Some studies suggest that the frontal lobe is underdeveloped in children and adults with ADHD.^[5][6] The frontal lobe is involved in executive function, attention, planning, impulse control, motivation, and decision making. In some cases the development is delayed, but catches up to expected standards by adulthood; in other cases, the frontal lobe never fully develops.

In general, ADHD is treated with stimulants. While this may seem counter-intuitive (why give a hyperactive child a stimulant?), when you understand the neurological processes involved, it makes a lot of sense. There are two ways that stimulants may work to help people with ADHD focus. Some researchers have found that the stimulants activate the underdeveloped parts of the brain (prefontal cortex and frontal lobe) thereby making these brain areas function more as they should.^[7] This allows the child or adult to focus properly. Other researchers suspect that the stimulants affect the way the neurotransmitters function in these brain areas, leading to better function in those areas.^[8][9]

There is still a lot of controversy about medicating children with ADHD. While there is clear evidence that medication works to control the negative effects of ADHD, there are also negative side effects that must be dealt with including problems sleeping, changes in appetite, headaches, and more. Further, the long-term effects of medicating young children are not well understood. For these reasons, many parents prefer an intervention that does not involve medication. The most common non-pharmaceutical intervention for ADHD is Cognitive Behavioral Therapy (CBT). CBT works by helping children to become aware of their thought processes, and then to learn to change those thought processes to be more beneficial or positive.^[10] CBT can also help by educating parents about ways to help their children learn about self-control and discipline. There is very good evidence that CBT is an effective strategy in treating ADHD. Indeed, in some studies, children treated with CBT have better long-term outcomes than children treated with medication. Some studies show that a combination of medication and CBT is most beneficial because the medication helps with behavior change more quickly, allowing for the child to learn through CBT more quickly. The CBT then helps with longer-term behavior change so that the child can stop taking medications and deal effectively with their ADHD symptoms based on what they have learned through CBT.