Introduction to Learning and Vision Therapy: Opinion Part I – DSM-V

DSM-V, Diagnosis, and the Value of Labels

In May of 2013, we moved on from the DSM-IV way of approaching diagnosis and coding, and moved 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 signs and symptoms be present to qualify for any 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. The DSM has little regard for the underlying causes of a disorder, or whether the DSM criteria themselves 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 (or hope) 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 solely 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 also 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

https://www.psychiatry.org/patients-families/specific-learning-disorder/what-is-specific-learning-disorder

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

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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 and development, or ‘VILD’ will never perform to their cognitive ability on standardized tests. Likewise, significant VILD when left uncorrected will lead to surprising and even alarming cognitive, motor, social and affective behaviours.]

To be diagnosed with a specific learning disorder (SLD), a person must meet four criteria.

1. Have difficulties in at least one of the following areas for at least six months despite targeted help:
   • Difficulty reading (e.g., inaccurate, slow and only with much effort).
   • Difficulty understanding the meaning of what is read.
   • Difficulty with spelling.
   • Difficulty with written expression (e.g., problems with grammar, punctuation or organization).
   • Difficulty understanding number concepts, number facts or calculation.
   • Difficulty with mathematical reasoning (e.g., applying math concepts or solving math problems).
2. Have academic skills that are substantially below what is expected for the child’s age and cause problems in school, work or everyday activities.
   • This criterion requires  academic skill challenges to be based on standardized achievement measures and “comprehensive clinical assessment.”
3. The difficulties start during school-age even if some people don’t experience significant problems until adulthood (when academic, work and day-to-day demands are greater).
4. Learning difficulties are not due to other conditions, such as intellectual disability, vision or hearing problems, a neurological condition (e.g., pediatric stroke), adverse conditions such as economic or environmental disadvantage, lack of instruction, or difficulties speaking/understanding the language.

A diagnosis is made through a combination of observation, interviews, family history and school reports. Neuropsychological testing may be used to help find the best way to help the individual with specific learning disorder. For individuals over age 17, a documented history of learning impairment may be substituted for the standardized assessment.

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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 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.

Introduction to Vision & Learning Therapy Index – Principles – Clinically Speaking – Opinion – All