Misattributing Learning Disorder Symptoms to Psychopathology

Diagnostic overshadowing between psychiatric and learning disability symptomology is a well-recognized phenomenon and can occur even with experienced mental health workers (Reiss S, 1983). Also known as misattribution, it is defined as the attribution of behavior to an incorrect or incomplete cause, behavior, or set of events. These incorrect assumptions can lead to a host of preventable problems or misguided treatment. A few possibilities include:

• A child who is not turning in homework may be called unmotivated, forgetful, hostile/angry, oppositional, or lazy. Their behavior might instead be due to a math or writing disorder.
• A child might talk a lot, stand more closely to others than expected, blurt out answers, or have difficulty waiting their turn, all of which can create social difficulties with peers or authority figures. Their challenges regulating their emotions in the usual way can be considered "bad, negative, defiant, disobedient, and hostile" behavior.
• A child who is habitually late for school, with attendance issues, displays excessive anxiety and worry, or engages in risky behavior could have executive functioning and time management issues.

Several learning disabilities could be the actual cause of these undesirable behaviors. Diagnosing them as "behavioral problems" will not address the issue and means the child will not receive relevant support. A comprehensive neuropsychological (psychoeducational) assessment is therefore critical to the prevention of misattribution. Accurate assessments help clinicians better understand interactions between Specific Learning Disabilities (SLD) and learning disorders and their impact on the learners' psychology. This aids in treatment planning, helps to prevent misattribution, and determines whether eligibility for an SLD has been met under IDEA, Section 504, or ADA (Learning Disorders Across the Lifespan: A Mental Health Perspective, Broitman and Davis, 2023).

An accurate diagnosis to aid treatment: The case of Justin

Justin was a second-grader struggling with reading. Therefore, he was underperforming academically and becoming increasingly anxious about attending school. Fearing that this might develop into school refusal, his parents consulted with a child psychiatrist. He was referred for twice-weekly play therapy, but his academic difficulties did not subside.

His teacher suggested a neuropsychological evaluation. The assessment revealed that Justin was experiencing phonological processing challenges, also known as dyslexia, as well as symptoms associated with ADHD, and he was diagnosed with both. This comprehensive assessment revealed that Justin's anxiety was secondary to dyslexia and ADHD, which needed to be diagnosed and treated to help the anxiety abate.

Knowing the cause of Justin's anxiety was the key to providing accurate treatment. ADHD medications, for example, will not work if a child's inattention or disruptive behavior is caused by anxiety, not ADHD. Likewise, anxiety medications will not help ADHD. Similarly, play therapy to improve confidence and enjoyment at school was not addressing the underlying learning differences caused by dyslexia and ADHD. It is only by understanding accurately what is going on that appropriate support could be implemented.

Preventing misattribution: The case of Mikah

Mikah was a third-grader in a mild to moderate special day class. Unfortunately, he was making very little academic progress, and his teachers believed he was becoming less cooperative when asked to do things in class. His parents sought out a second comprehensive evaluation.

These findings indicated that the language disorder was more in the moderate to severe range. Mikah was not actually "not cooperating," but rather, he really did not possess the vocabulary necessary to understand the directions being provided to him. This is an example of a common misattribution whereby the surface behavior is interpreted one way, in this case as non-compliance, whereas the underlying cause, lacking the basic concepts necessary to follow directions, a "hidden disability," is not understood or perceived.

Confirming eligibility: The case of Sarah

Sarah had done well in a public elementary school but began to complain to her parents about math in middle school. A tutor helped Sarah get through middle school. In high school, however, abstract math and more mathematically demanding sciences caused her to struggle even more, and she seemed depressed. A student study team met to discuss options, including her counselor, the school psychologist, a special education teacher, and Sarah and her parents. At the meeting, it was decided that Sarah needed more accommodations to successfully complete her math requirements, and a psychoeducational evaluation would determine if she qualified for an IEP or a Section 504 Plan.

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Testing revealed strengths in verbal reasoning, verbal memory, attention/concentration, reading, and aspects of written expression, while weaknesses were evident in visuospatial reasoning, quantitative reasoning, visual-spatial memory, math problem-solving, and aspects of written expression. This pattern of cognitive and academic strengths and weaknesses was consistent with a Nonverbal Learning Disability, and Sarah qualified for either an IEP or a Section 504 under the SLD eligibility code with a visual processing disorder in the mild to moderate range. This enabled the team to add active interventions as well as accommodations to aid Sarah in graduating from high school. An earlier diagnostic or eligibility evaluation could have helped to prevent her depression, but luckily this better understanding and the interventions for her learning disability lessened its impact.

Losing precious time

In each of these cases, time was lost due to the lack of sufficient data to make the most appropriate diagnoses. When you have ongoing headaches, you know there are many possible causes, ranging from mild to very serious. Your doctor will ask you detailed questions about how long the headaches have been taking place, what type of pain you are feeling, when they occur, and what other symptoms you're experiencing.

Without a thorough assessment and examination, it would be absurd for your doctor to diagnose you with a brain tumor or the flu, both of which can give you a headache. And, of course, the treatment for a brain tumor and a virus would look very different. That's why a good mental health professional will give your child a thorough evaluation based on a broad range of information before coming up with a diagnosis. It is crucial to understand what's really behind a given behavior because, just as in medicine, the diagnosis your child receives can drastically change the appropriate treatment.