Introduction to Learning and Vision Therapy: Opinion Part I

DSM-V, Diagnosis, and the Value of Labels

In May of 2013, we will all be asked to let go of our previous comfort with the DSM-IV way of approaching diagnosis and coding, and move on to DSM-V. The focus of the Diagnostic and Statistical Manual has always been to standardize the conversation between medical and psychiatric practitioners worldwide, to provide a common ground from which to launch discussion and research.

In the world of statistics and scientific opinion, it is common to limit one’s perspective to that of one’s own professional affiliation and either neglect or outright ignore other perspectives from other fields of study. In the case of DSM, for example, it is only important that certain features be present to qualify for the diagnosis. Like a game of psychiatric bingo, it’s a race to fill in the blanks and arrive at some reasonably good match to one of the criteria referenced in the diagnostic manual. There is very little regard given to the underlying causes of a disorder, or whether the DSM criteria are even a valid means of describing what is seen: It is simply assumed that one category or another will work, and given that diagnosis, there is a further assumption of a neurochemical (read ‘brain disorder’) basis to the behaviour.

So, what then? If, for example, a child presents with a diagnosis of specific learning disorder, what does this mean to us as developmental professionals? Well, not much.

Rather than liberate the child, the parent, and the therapist, it provides more questions than answers – including a great sense of wonder as to the value of undergoing extensive testing to arrive at a ‘firm’ diagnosis in the first place. We can say that having a DSM diagnosis helps us in determining steps to take in therapy, and certainly this helps in unlocking public funds to try to help a child in and out of school. While the latter is clearly a pragmatic benefit, it is so only if it assists in making therapy meaningful.

Developmental professionals do what they do, and they do so based on their own observations with children. A diagnosis is potentially helpful, but only if you don’t know what you’re looking at.  It is best to trust instinct and to proceed with therapeutic activities that can be shown to be effective for that child at a level suitably comfortable and challenging to be fruitful.

Relying on a DSM diagnosis for therapy can also be downright dangerous. In my own clinic, each week presents new children who have been labeled by DSM standards and some therapy initiated as a consequence. Frequently enough, the child has some sort of problem with visual signal acquisition (finding, targeting, tracking, and making sense of visual stimuli). The problems are exposed during testing, but they expose themselves through other complex behaviour expressed by the child to either avoid or facilitate the tasks given to them.

This program will explore in more detail how difficult vision can and will alter a child’s development in subtle and profound ways. In moderate to severe cases, it is not uncommon for the child to not only show signs of struggle in the classroom, but also other medical concerns. Relying on a DSM diagnosis can close the doctor’s, teacher’s, and therapist’s mind as to possible causes. Only by addressing the underlying causes  of aberrant behaviour can we hope to help. Reading therapy for a child with significant visual impairments to learning, for example, is like filling a bucket that’s full of holes – it’s resource intensive, wasteful, frustrating, and more than a little cruel to the child.

The proposed DSM-V ‘Neurodevelopmental Disorders’ includes “08 Specific Learning Disorder”. Here it is described as quoted from

http://www.dsm5.org/ProposedRevision/Pages/NeurodevelopmentalDisorders.aspx

with comments in square brackets to illustrate the points made above:

A diagnosis of Specific Learning Disorder is made by a clinical synthesis of the individual’s history (development, medical, family, education), psycho-educational reports of test scores and observations, and response to intervention, using the following diagnostic criteria. [Children with significant visual impediments to learning, or ‘VIL’ will never perform to their cognitive ability on standardized tests.]

A.     History or current presentation of persistent difficulties in the acquisition of reading, writing, arithmetic, or mathematical reasoning skills during the formal years of schooling (i.e., during the developmental period). The individual must have at least one of the following: [All of these can and will be caused by significant trouble with vision.]

1.   Inaccurate or slow and effortful word reading. [Very common with difficult vision.]

2.   Difficulty understanding the meaning of what is read (e.g., may read text accurately but not understand the sequence, relationships, inferences, or deeper meanings of what is read. [These children will often do better when things are read to them in short pieces.]

3.   Poor spelling (e.g., may add, omit, or substitute vowels or consonants). [Some children will adapt to difficult vision by relying on hearing and auditory memory, which is not always accurate when the words on the page cannot easily be deciphered.]

4.   Poor written expression (e.g., makes multiple grammatical or punctuation errors within sentences, written expression of ideas lack clarity, poor paragraph organization, or excessively poor handwriting). [Vision guides motor movement and if it is impaired, both gross and fine motor control will also suffer noticeably.]

5.   Difficulties remembering number facts

6.   Inaccurate or slow arithmetic calculation

7.   Ineffective or inaccurate mathematical reasoning.

8.   Avoidance of activities requiring reading, spelling, writing, or arithmetic. [Partly because these activities require near work and strong visual signal acquisition skills, which are especially taxing to children with farsightedness, amblyopia, astigmatism, and muscle control problems.]

B.     Current skills in one or more of these academic skills are well-below the average range for the individual’s age or intelligence, cultural group or language group, gender, or level of education, as indicated by scores on individually-administered, standardized, culturally and linguistically appropriate tests of academic achievement in reading, writing, or mathematics. [Children who struggle with vision will show reduced academic performance regardless of ability. Some visual impediments are strong enough to grossly change a child’s personality and social interaction.]

C.     The learning difficulties are not better explained by Intellectual Developmental Disorder, Global Developmental Delay, neurological, sensory (vision, hearing), or motor disorders.

D.     Learning difficulties identified in Criterion A (in the absence of the tools, supports, or services that have been provided to enable the individual compensate for these difficulties) significantly interfere with academic achievement, occupational performance, or activities of daily living that require these academic skills, alone or in any combination.

Descriptive Feature Specifiers

Specify which of the following domains of academic difficulties and their subskills are impaired, at the time of assessment:

1.   Reading

a) Word reading accuracy

b) Reading rate or fluency

c) Reading comprehension

2.   Written expression

a) Spelling accuracy

b) Grammar and punctuation accuracy

c) Legible or fluent handwriting

d) Clarity and organization of written expression

3.   Mathematics

a) Memorizing arithmetic facts

b) Accurate or fluent calculations

c) Effective math reasoning 

Comments: The comments should not be taken to mean that all learning and reading problems come from difficult vision. It is clear, however, that many cases of behavioural and learning concerns are mis-labeled simply because the child’s visual developmental status was never assessed. Addressing visual concerns in these cases often obviates the need for the label and opens the door to effective remedial therapy. The reality is that we do live with ‘tags’: If we, as developmental professionals, can keep a healthy skepticism and distance from a label when it comes to therapeutic management and stick to what is known to work, rather than what the label prescribes, children will benefit from the resources provided by the ‘tag’ itself.

Final Note: The proposed DSM-V also includes the category “Neurocognitive Disorders” which is a list of disorders currently proposed for inclusion this diagnostic category, and formerly listed in DSM-IV under the chapter of Delirium, Dementia, Amnestic, and Other Cognitive Disorders. These disorders are not the primary focus of this short course on learning and vision therapy, which targets primarily the pediatric patient.

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