Written Expression Learning Disorder Workup

The Diagnostic and Statistical Manual of Mental Disorders, 4th edition (DSM-IV) and the International Classification of Diseases, 9th edition (ICD-9) offer medical classification systems that are similar to, but not always consistent with, educational definitions of learning problems.^[4] The medical diagnosis of a learning disorder does not automatically provide a child with eligibility for assistance at school. Therefore, understanding the educational definitions and school processes that allow for school interventions is important for clinicians who diagnose learning problems.

The disorder of written expression, like the other learning disorder diagnoses provided in the DSM-IV, is coded on Axis I. The DSM-IV uses the terminology learning disorders, replacing the former term, academic skills disorders, used by the Diagnostic and Statistical Manual of Mental Disorders,3rd edition revised (DSM-III-R). Previously, in DSM-III-R, the disorder of written expression was called developmental writing disorder and was coded on Axis II.

Criteria for diagnosis

The DSM-IV diagnosis of disorder of written expression includes writing skills substantially below those expected for the child by age and measured intelligence. Poor writing skills must result in a significant interference with academic achievement and/or the activities of daily living that require the composition of texts (ie, grammatically correct sentences and organized paragraphs). In contrast to the previous editions, the DSM-IV allows for concurrent diagnosis of disorder of written expression with sensory, motor, neurological, and intellectual conditions; however, if a patient is concurrently diagnosed with any of these, the writing skills difficulties must be in excess of those usually associated with the condition.

Further, poor spelling or handwriting alone, in the absence of other writing difficulties, is insufficient for the diagnosis of disorder of written expression. For children with poor motor coordination that causes poor handwriting, a diagnosis of developmental coordination disorder may be appropriate. The DSM-IV specifically indicates individually administered standardized tests or functional assessment of writing skills and measured intelligence. Therefore, diagnosis according to DSM-IV criteria involves psychoeducational evaluation.

Special education and learning disabilities

In educational settings, the terminology specific learning disability is used. The term learning disability originated with Public Law 94-142, which defined handicapping conditions of children as disorders in understanding or using language that result in specific academic deficits, including writing. Law mandates that public schools provide special education services for students who have such disabilities. The Individuals with Disabilities Education Act (IDEA) guides the actions of school committees on special education in determining the eligibility for special services of students through age 21 years.

Differential diagnosis

Similar to the DSM-IV criteria, special education committees' determinations do not define a learning disability in written expression as handwriting and spelling unless accompanied by other written expression problems. As with all learning disorders, differentiating situations in which children who have difficulty writing have other medical, developmental, physical, or sensory impairments, deficient educational opportunities, environmental deprivation, or cultural differences (including English as a second language), which may contribute to the poor achievement in written expression, is necessary.

A diagnosis of mental retardation usually rules out any learning disorder, as the general deficit in intellectual skills is equivalent to a picture of overall low academic performance. In some cases of mild mental retardation, a specific learning disorder such as disorder of written expression could occur if the skills in writing are lower than would be expected given the potential intellectual functioning of the child.

Careful attention to the neurological history and examination should rule out other factors that can cause symptoms of dysgraphia or phonological agraphia, such as injury to or vascular abnormalities in the posterior corpus callosum or superior temporal gyrus or epilepsy (a cause of acquired epileptic dysgraphia).

Symptoms of anxiety or frustration (breaking pencils, crumpling or tearing up homework papers, avoidance of academic work) should not be ignored because, for many children, these symptoms correlate with an untreated learning disorder and should not be regarded as only reflecting the presence of a comorbid disorder.

Taking a careful history for comorbid disorders is important because some children present with comorbid attention deficit hyperactivity disorder (ADHD), oppositional defiant disorder, features of obsessive-compulsive disorder (OCD), and/or seizure disorders.^[5]

Learning disability determination in educational settings

In school settings, a teacher often first notes indicators of a learning disorder. At that point, a child may be referred to the committee on special education to determine if the child is eligible for special services. Those outside of the school, such as parents or physicians, may also refer a child for this determination. If parents consent to a special education evaluation, schools provide a professional assessment, including a psychoeducational evaluation, for the committee's review. Parents have the right to present additional information and assessments obtained from other professionals.

The law mandates that children be provided with the least restrictive environment in school that addresses their disability. This means that a diagnosis of a learning disorder and a determination of eligibility by the committee on special education will not result in unnecessary changes in the child's class or school assignments. For many children, the special education services are the main avenue of treatment available to them. Specific laws define the parents' and child's rights to disagree with and to appeal committee determinations.

A medical diagnosis of a learning disorder may or may not be sufficient to establish eligibility for special services, depending on the discrepancy between intellect and achievement used for the diagnosis and the individual school district. The discrepancy needed to diagnose a learning disorder is defined by DSM-IV criteria as achievement that is substantially below intellect. Substantially below refers to more than 2 standard deviations between the scores on 2 tests; this is a standardized measure of achievement and a measure of intellectual functioning. This difference can be less, between 1 and 2 standard deviations, if the intellectual assessment has been impacted negatively by a cognitive or other mental or medical disorder.

In assessments of written language, functional writing skills are also used as a measure of achievement. Although the evaluation of the writing samples is always recommended and is necessary for a functional assessment of the disorder, some subjectivity is involved in this type of assessment. Inter-rater reliability of writing samples can be poor.

Committees on special education generally determine which children are designated as having a learning disability by applying a specific discrepancy formula to the difference between intellectual and achievement test scores to all cases in their school district. States and individual school districts vary considerably in which statistical method they use to determine the intellectual/achievement test score discrepancy.

Formulas that include consideration of standard scores and the regression effects of intellectual/achievement discrepancies are considered most accurate; however, all methods can be criticized as being less than scientific. A child can meet the criteria for eligibility for special services in one school district and not in another. Criticism of this system of determining disabilities is not uncommon. Consulting professionals familiar with the psychometric properties of achievement and intellectual tests and their use in special education determinations may be helpful. In addition, many school districts now include failure of response to remedial educational interventions as a criteria for diagnosis.

Referenced tests assess written expression

• Test of Written Language, 3rd edition measures (1) contrived writing including vocabulary, spelling, style (capitalization and punctuation); logical sentences (writing conceptually sound sentences); and sentence combining (measuring syntax) subtests; and (2) spontaneous writing (scored for thematic maturity, contextual vocabulary, syntactic maturity) for children aged 7 years and 6 months to those aged 17 years and 11 months.^[6]
• Test of Early Written Language, 2nd edition measures basic, global, and contextual writing quotients for children aged 3 years to those younger than 11 years.^[7]
• Test of Written Spelling, 3rd edition measures the spelling of phonetically regular and irregular words for children aged 6-18 years.^[8]
• Kaufman Test of Educational Achievement includes a spelling subtest with analysis of error types for children aged 6-17 years.^[9]
• Wechsler Individual Achievement Test includes spelling and written expression subtests for children aged 5-19 years.^[10]
• Peabody Individual Achievement Test includes a spelling subtest with a multiple-choice format and a written expression subtest for children aged 5-18 years.
• Woodcock-Johnson Psychoeducational Battery, revised includes dictation, proofing, writing fluency, and writing samples subtests for children aged 5 years to adulthood.^[11]
• Slingerland Screening Tests for Identifying Children with Specific Language Disabilities may be helpful.
• McCarthy Scales of Children’s Abilities is a normed test that can be helpful in identifying multiple deficit areas.
• Detroit Tests of Learning Aptitude is another normed test that is also helpful in identifying multiple deficit areas.