In the final section of Module 13, we will discuss matters related to intellectual disability and learning disorders. Be advised a more thorough description of these disorders is beyond the scope of this book, but you can read more in the Behavioral Disorders of Childhood OER by Kristy McRaney, Alexis Bridley, and Lee Daffin (2021) by visiting:
What is Intellectual Disability?
At the core of an Intellectual Disability is a deficit in cognitive or intellectual functioning. Historically, we labeled individuals with this presentation of deficits as having Mental Retardation. Due to significant stigma and social misuse of the term, when the DSM 5 was published, the term changed from Mental Retardation to Intellectual Disability (also described as an Intellectual Developmental Disorder). While the terms Intellectual Disability and Intellectual Developmental Disorder are considered interchangeable, we will use the term Intellectual Disability (ID) for the purposes of this book. This disorder leads to two primary areas of major deficits – cognitive functioning and adaptive functioning (APA, 2013).
Cognitive functioning.
Cognition or intellectual functioning refers, in a general sense, to our ability to problem solve, understand and analyze complex material, absorb information from our environment, and reason. An individual with ID has a significant deficit in this area. Cognitive functioning is most often measured using an intelligence test (more on this later in this chapter). An IQ score under 70 – 75 indicates a severe deficit in cognitive functioning, although there is some flexibility within this criterion.
Adaptive functioning.
Adaptive skills are skills that help us navigate our daily lives successfully such as understanding safety signs in our environment, making appointments, interacting with others, completing hygiene routines, etc. Essentially, these are the skills that one would ultimately need to live independently. Individuals with ID typically have adaptive skills that are far below what would be expected given their chronological age. This is typically measured by a standardized scale (more on this later, as well).
When both cognitive and adaptive functioning is delayed, the likelihood of ID is high. ID is also categorized into different severities based on the level of delays related to adaptive functioning. The more support someone needs, the more severe the ID diagnosis. Severity ranges from mild (least severe), moderate, severe, and profound (most severe; APA, 2013).
ID is present in the early neurodevelopmental period. As such, it is most frequently diagnosed in children. ID is not something one would “acquire” in adulthood. If an individual experiences cognitive and adaptive function decline in later years, this is not considered ID (which is a neurodevelopmental disorder) but is more likely a neurocognitive disorder that may be due to several things (e.g., traumatic brain injury, dementia). As such, although an individual can go undiagnosed until adulthood, and then as an adult be diagnosed with ID, there must be significant and indisputable evidence of cognitive delay and adaptive functioning delay in the early developmental time period. Otherwise, an adult would not be diagnosed with ID.
What Are Specific Learning Disabilities?
A learning disorder is characterized by the inability or difficulty processing academic or functional information in our environment (APA, 2013). Despite an ability to cognitively achieve similar to peers, an individual is delayed in learning in a particular area. More specifically, academic tasks are challenging within one or more areas, which results in significant academic impairment (APA, 2013). Historically, we diagnosed LDs when there was a significant discrepancy between an individual’s cognitive/intellectual ability (as measured by an intelligence test) and their academic achievement (as measured by a standardized achievement test) as this was required by the DSM-IV-TR criteria. This method is referred to as the discrepancy model. While many still do this, and there is nothing in the DSM 5 that disallows this practice, the DSM 5 criteria were rewritten to allow for more flexibility. Ultimately, a discrepancy between one’s IQ and academic achievement is no longer required; however, there must be specific data that indicates an individual is performing significantly below what would be expected given their age.
In addition to significant academic deficits, there must be evidence that efforts (e.g., tutoring, increased and specialized instruction) to improve one’s abilities within the specific area have been made, before assigning a diagnosis of an LD. This is to ensure that an individual has had full access to educational material and support before a professional assigns a diagnosis to them. In school systems, tiered interventions have come into play (more on this in the Interventions section).
When considering LDs, there are three specific areas that are considered: reading, mathematics, and written expression. For example, a professional would diagnose an individual with a specific learning disorder with impairment in reading. An individual may have a diagnosis of only one LD, or multiple LDs.
Reading — This relates to an individual having difficulty in reading, may that be in comprehending material, reading fluently and quickly, or reading words accurately.
Mathematics — This may be related to simple calculation abilities such as math facts or more complex problem-solving and reasoning abilities.
Written expression — This may refer to the ability to accurately spell words or punctuate and use correct grammar, or it may include one’s ability or create written work that is well-organized and comprehendible.
Matters of dyslexia and dyscalculia.
Technically, dyslexia and dyscalculia are not actual diagnoses in the DSM 5; rather they are alternative terms used to describe learning disorders in reading (dyslexia) and math (dyscalculia). Dyslexia is the presence of a significant deficit related to fluent word recognition, decoding, and spelling (APA, 2013). Dyscalculia is the presence of significant deficits related to “problems processing numerical information, learning arithmetic facts, and performing accurate or fluent calculations” (APA, 2013). Although these two terms are used very frequently in school systems and by other professionals such as speech/language pathologists they are considered alternative terms in the DSM 5, not diagnoses, and as such psychologists cannot use these terms when diagnosing a patient. Instead, they assign a diagnosis of specific learning disorder with impairment in reading (for dyslexia) and a specific learning disorder with impairment in mathematics (for dyscalculia). They can provide an explanation and rationale that the individual’s deficits are characteristic of the pattern of deficits seen in individuals with dyslexia or dyscalculia. This is an excellent example of how professionals sometimes will discuss the same phenomenon but use different terminology.
Differences and Similarities between ID and LD.
Although ID and LDs may seem very similar, it is important to not confuse the two as they are different. When thinking about both disorders, we have three different core areas to consider: adaptive functioning, cognitive/intellectual ability (IQ), and academic achievement. A rudimentarily way to think about this is — with ID we are concerned with adaptive functioning and IQ and with LD we are concerned with IQ (sort of) and academic achievement. Although IQ matters (sort of) in both disorders, the reason they are important vary slightly. However, because IQ is considered in both disorders, people often intertwine and confuse the two disorders.
Think about it like this: IQ essentially is what we are cognitively able to do — what we can do. Adaptive skills and academic achievement is what we are doing.
Intellectual disability.
If we cannot perform in the average range on an IQ test and we are not performing daily living tasks appropriately (for our particular age — let’s not forget that we would not expect a 7-year-old to make their own doctor’s appointment. We would, however, expect a 7-year-old to know to dial 911 in an emergency), then this is indicative of an ID.
If we can achieve an average level of skill (meaning our IQ is average), but we are not achieving an average level of academic achievement in an area, that leads us to be puzzled, right? If we can do something, but we are not, that does not make sense. But what if we cannot perform average (meaning our IQ is not average, but substantially below average)? Would we expect the individual to perform averagely on academic tasks? For example, if someone’s IQ is 65 (cannot function typically on a cognitive task) would we expect them to have an academic achievement score of 100 (remember, this is their “is or is not doing/performing)? That is a 30-point jump from their ‘can’ to their ‘are doing’. We would not necessarily expect this, right? We would expect that if someone’s IQ is a 70 to have an academic score of around a 70. This isn’t necessarily an LD; it is reflective of low achievement due to low cognitive abilities resulting from ID. However, if that person’s IQ was 100 (can) and they scored a 70 (is not performing) on an academic achievement task, we would be concerned about an LD because what they are doing is not matching and measuring up to what they, theoretically, can do.
LDs in the cognitively delayed and in the cognitively gifted.
Individuals with extreme cognitive functioning abilities often get overlooked. For example, children that are gifted, but have a reading disorder, often go undiagnosed. Think about it, their weaknesses, although areas of deficit for themselves, look like average abilities to others around them. You might be asking yourself what I mean by this. An example should help.
A 2nd-grader with a high cognitive ability gets all As. She excels in math and writing. In fact, she is far past her peers in these areas. She has long learned her multiplication and division facts and is even working on some basic geometry skills. She has a great ability to write and has been drafting paragraphs with ease and has even started learning to write essays. She loves math and writing, but she dislikes reading. When in class, she reads just like her peers, no more advanced, but right on 2nd-grade-level expectations. She finds reading to be more difficult, though, and it does not come nearly as easy as math and writing. However, because she is on track compared to her peers, her teachers and parents do not recognize any issues — her grades are fine and her school standardized testing is not a problem.
What if I told you that her standardized math and writing scores matched her intellectual ability (meaning her can and is/are matched) but her reading score (is/are), although average, was well below what would be expected given her IQ (can) and is much lower than her math and writing scores (despite still being an acceptable score). Would you say she may have a reading disorder? If you said yes, you are right. If you said no, you may be right too. Fact is, this is a gray area. The old DSM would have made it easy to diagnose this child with an LD in reading. The new DSM makes it a bit tougher. However, one would be inclined, if this reading deficit (compared to her own abilities) caused impairment (internal distress, preventing her from advancing in math and writing because her reading abilities were lagging behind the other abilities), to diagnose her with an LD in reading. It is easy to see how this child would be missed and go undiagnosed for years.
Now let’s reverse the scenario. Let’s take a 2nd grade girl who has a diagnosis of an ID. She struggles in all academic areas but her math abilities are even more behind than her reading and writing. Do you think one could make a case for an LD in math? Theoretically, they could. But it takes a lot of careful documentation of intervention attempts (see RTI discussion) and standardized testing that makes it undoubtably clear that this is true (similar to the above example).
Essentially, when individuals have an IQ that falls to the extreme (low or high), their weaknesses are often missed. As such, providers and educators must be careful and mindful to not overlook potential LDs in these individuals.
Community supports and programs.
For individuals with ID, community supports may be critical during childhood, and even more so as the individual transitions to adulthood. Community supports may include organizations devoted to socialization and family support. For example, The Arc is an incredible organization that is devoted to serving individuals with developmental delays, including but not limited to ID. They often engage in advocacy efforts and offer training for the community and professionals. Moreover, they offer employment services for individuals with ID or other developmental delays. Local chapters will often host social gatherings and events for individuals and their families (The Arc, 2018). Typically, there is an Arc chapter in most major cities and areas. Other community supports may involve government-funded programming for living arrangements, supplemental income, etc.
As individuals’ transition to adulthood, some programming may need to be considered related to home/living arrangements. Historically, individuals with ID were often institutionalized. However, in recent years, a strong push to deinstitutionalize care, and provide group and community home options has occurred. As such, a more common and inclusive living option for individuals may be a group home in which multiple individuals live in a home-like setting and have constant supervision and medical care as well as transportation. Another option, often referred to as supported independent living, is a situation in which fewer, perhaps four individuals, live in an apartment or similar setting, and are provided constant supervision by one individual. This is a less restrictive environment than a group home, as only one supervising staff member is present, and a nurse and other medical staff are not readily available. Moreover, individuals with ID are often capable of successful employment and these opportunities are provided in group and independent living home arrangements. Individuals with ID, depending on the severity of their intellectual impairment, may work in settings with routine tasks (e.g., assembling plasticware packets, bussing tables) in independent settings (e.g., employed independently within the community) or in ‘supervised workshops’ (i.e., settings where multiple individuals with disabilities are employed and provided significant help and supervision while working).
Education.
Individuals with an Intellectual Disability receive an Individualized Education Plan (IEP) at their school which is federally regulated, and implemented at the state level, through the Individuals with Disabilities Education Act (IDEA), established in 2004 (IDEA, n.d.). This was enacted to ensure fair and equal access to public education for all children. An IEP outlines specific accommodations and supports a child is entitled to in the educational setting so that they can access educational material to the fullest degree. Children with ID may receive typical academic instruction in an inclusion classroom, meaning they are in a general educational class. However, the more severe the disability, the more supports they may require. As such, this may mean the child is pulled out at periods of time to receive specialized instruction. Additionally, if the child’s disability is severe, they may be placed in a self-contained classroom which is a class with a small number of kids that all have a severe disability, oftentimes with several teachers/teacher aids. Supports and accommodations may include reduced workloads, extended time to master the material, increased instructional aid, etc. Additionally, supports may also go beyond specific academic areas. For example, social skills may be a focus of an intervention.
Individuals with severe deficits related to ID will eventually have to have a determination of diploma track or not. If an individual is not placed in a diploma track, they will receive a “certificate of completion” from high school, rather than a high school diploma. Non-diploma track supports might focus heavily on functional skills rather than traditional academics. For example, rather than worrying about mastering algebra, the individual’s education may focus on learning functional mathematics so that they will be able to successfully manage a grocery shopping trip/purchase.
Some college programs have been designed to allow individuals with developmental delays such as ID to access the college experience and receive specialized vocational instruction. For example, Mississippi State University’s ACCESS program (which is an acronym for Academics, Campus Life, Community Involvement, Employment Opportunities, Socialization, and Self-Awareness) is 4-year, non-degree program designed for individuals that have a developmental delay, including ID. Students receive a “Certification of Completion” within a specific vocational area when they complete the program. They live on campus and are able to access the full college experience (MSU, n.d.).
Psychotherapy.
Therapy is often underutilized in individuals with ID, despite beneficial impacts that research has shown when both behavioral and cognitive-behavioral therapies are utilized (Harris, 2006). Therapy often focuses on the emotional and behavioral impacts of ID, normalizing the individual’s experiences, and treating comorbid depression, anxiety, or other mental health conditions (Harris, 2006). Another area of strong focus may be increasing adaptive functioning skills. For example, helping the individual complete daily hygiene, chores, etc. and learn how to navigate their home and community safely, may be a focus of therapy.
Medication.
Medications to manage emotional or behavioral concerns that are occurring comorbid with an individual’s ID diagnosis may be beneficial. For example, if an individual has ID and depression, an antidepressant may be beneficial to help resolve some symptoms of depression. However, medications are not utilized to “treat” ID.
Treatments for Learning Disorders
Education.
Individuals with an LD receive an Individualized Education Plan (IEP) as well. Focus is placed on increasing instructional aids for the child. The child will often be pulled out for additional, one-on-one interventions in the academic area(s) of concern. Additionally, the child may receive additional supports such as extended time on tests and assignments, partial credit (when partial credit is not typically given in a particular class), and early access to study guides or access to study guides if a study guide is not regularly given in a particular class. A child may also be allowed to have tests read to them, especially on nonreading-related tests, such as history, when a reading impairment is noted. The reason for doing this is so that the child’s performance in the nonreading-subject (e.g., science, history) is not negatively impacted by their reading deficit. The child may also be able to verbally respond to test items and have a teacher write their answers. Moreover, the child may get opportunities to correct errors on tests for additional credit, etc. These are just examples of accommodations and are not an exhaustive list. The specific accommodations and supports that are implemented should be specific to the child, their deficits, and their current needs.
Tutoring, whether occurring in school or privately, is often useful as well. This simply increases exposure to material and provides additional support and intervention. Empirically-based tutoring methods are sometimes used, particularly for children with dyslexia.
Medication.
Like ID, medicine is not utilized to ‘treat’ an LD. However, given that ADHD is highly comorbid with LDs, ADHD-related medications may be utilized and beneficial. As chronic underachievement in an academic area may lead to anxiety and depressive states for some children, prescription medication (or psychotherapy) may also be utilized and beneficial.
