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Learning disability

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Learning disability

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USMLE® Step 1 style questions USMLE

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A 7-year-old boy is brought to the pediatrician’s office by his parent for evaluation of abnormal behavior. Over the past year, the patient has refused to go to school almost every morning. As the start of the school day approaches, he cries and screams that he “cannot go.” At school, the patient often has difficulty reading passages from books out loud and writes “random letters” on his assignments. He becomes easily frustrated in the classroom. In addition, the patient frequently confuses the order of words in sentences while speaking. The patient participates in karate after school and enjoys playing with his older siblings and other children in his neighborhood. Growth, vital signs, and physical examination are within normal limits. Which of the following is the most likely diagnosis?  

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Rishi Desai, MD, MPH

The DSM-5 defines specific learning disorders as a set of disorders that relate to having difficulty learning and developing certain skills for at least 6 months.

First, there’s dyslexia, which is difficulty with reading, then there’s dysgraphia, which is difficulty with writing, and finally there’s dyscalculia, which is difficulty with mathematics.

People can have difficulty with just one of those activities, but they can also have problems in all three areas.

These disorders are considered specific learning disorders because they don’t stem from another condition like an intellectual disorder or a global developmental delay, and they aren’t due to an obvious environmental cause like not being taught how to read, write, or do math.

Learning disorders are usually diagnosed during the school-aged years, when a child’s skill can be assessed and is found to fall significantly below the average of other children in their age group.

Dyslexia affects both oral and written communication throughout an individual’s life.

People with dyslexia often have trouble identifying letters or words, and this can result in slow, inaccurate, and effortful reading.

This often becomes obvious when a person with dyslexia is reading aloud, because they might have to hesitate or guess at words, and they might end up reading without normal intonation or expression.

Dyslexia can also cause difficulty with spelling because a person might add or omit letters by mistake.

Having to go through all of this extra effort with reading means that people with dyslexia might also have a hard time understanding what they’ve read, missing the deeper meaning of a passage, forgetting the correct sequence of events, or being unable to make inferences about what they’ve read.

Dysgraphia describes having trouble with writing: specifically, poor spelling and difficulty with grammar.

People with dysgraphia often have poor handwriting, even though they don’t have trouble with other fine motor skills, like, for example, using tweezers.

They might mix print and cursive writing, or might misuse upper and lowercase letters; as a result, their writing is often slow and labored, causing them to get writing fatigue.

Dysgraphia can also involve more global writing problems like having difficulty putting thoughts down on paper, or thinking and writing at the same time, which, as you might guess, leads to writing that lacks clarity and cohesion.

Finally, there’s dyscalculia.