Amer. 1. Orthopsychiat. 48(4), October 1978

DIAGNOSTIC CLASSIFICATION OF LEARNING PROBLEMS: Some Data howard

S. Adelman, Ph.D.

University of California, Lor Angeler

Despite the large body of literature on diagnoses related to learning problems, little systematic information has been gathered on the specific labels assigned by professionals and the bases for their determination. In this study of children enrolled in a clinical school program, only one diagnosis out of fifteen resulted from a consistent pattern of test findings, while over half the diagnoses were based primarily on observation, and a third were arrived at despite contradictory evidence. Implications for current clinical and research practices are considered.

he focus on potential negative side effects of labeling children has led to some advocacy against any labeling of children. Such advocacy fails to recognize that valid classification is an indispensible activity facilitating both research and practice. Furthermore, these one-sided critiques tend to divert attention from the task of correcting major problems related to valid diagnosis, i.e., the inadequacies o f current classificatory schemata and the deficiencies of the methods used in arriving at diagnostic classifications. This is not to say that these problems have been ignored (see, as a small sample of the

T

literature in this area 4 . 6 . 8 , 0,11-17. 1Ot222 4 . 2 7 ) . It is just that acknowledgement of the existence of these assessment problems has become so much a part of the fabric of textbook and related literature discussions and of training program curricula that they tend to fade into the background and become accepted as the standard for practice. Therefore, it is important to continue to document the state of current practices and discuss the profound implications contemporary activities have on children and on the advancement of knowledge-not as criticism per se, but to provide systematic data that can pinpoint problem

Submirted fo rhe Journal in January 1978.

717

DIAGNOSTIC CLASSIFICATION

areas and stimulate efforts to correct unsatisfactory clinical and research practices. Despite the large amount of literature in this area, little information has been gathered concerning the specific diagnostic labels being assigned children with learning and behavior problems, and the bases upon which these diagnoses are determined. The few recent studies in this area suggest that current practices may be much less than satisfactory. For example, one study *l found that, of 208 school-labeled learning disabled children, 37% did not meet a criteria of normal intellectual ability, i.e., in this instance, using the WISC-R, they did not have a full scale IQ of at least 76 and either a Verbal or Performance IQ of at least 90. In another study,20 a sample of 48 physicians, questioned regarding the data they used in forming a diagnosis of hyperactivity, indicated that such diagnoses were made primarily on the basis of behavioral indicators and medical history, rather than from other data gathered during the physical examination. Other studies have found no differences in “diagnostic” test battery findings between a group of children with specific problems (i.e., persistent reversal errors in handwriting seen as reflecting problems in spatial orientation) and a control group. In a process study related to diagnostic proc e d u r e ~ , *clinical ~ psychologists were found to stress the subjective, insightful, and experiential nature of testing, and personal clinical experience was emphasized as more important in their test-use decisions than pragmatic or psychometric considerations. While limited, such studies are beginning to present a quantitative as well as qualitative picture of current diagnostic practices.

METHOD

As a first step, a questionnaire was sent to the families of the 61 students enrolled at the beginning of 1977 in classrooms at Fernald, a laboratory and clinical facility of the Department of Psychology at UCLA, noted for its work with learning problems. The classroom program is designed to serve a learning problem population 6-1 8 years of age. Using currently accepted professional standards, it is unlikely these youngsters, as a group, could be distinguished from those in special classes and schools %forthe learning disabled/disordered in most parts of the country. The parent questionnaire asked what labels, if any, had been applied to the youngster, by whom, and at what age. Thirty-eight families chose to respond with the requested information (three declined and 20 did not respond even after follow-up requests). Of the 38 respondents, six indicated their children had not been assigned any label and another six chose not to provide necessary signed releases allowing contact with professionals who had done the diagnoses. This left a sample of 26 labeled children for the investigation of the bases for the diagnoses. For this phase of the study, it was decided to mail an open-ended request to the original diagnosticians. Since some youngsters had been diagnosed several times, with the same or different labels, 36 requests were sent out. The material sent included the signed release, a stamped return envelope, a statement describing the study, the diagnostic label the parent indicated had been assigned by the professional, and the request for information and any other material that

HOWARD S. ADELMAN

would aid in interpreting the bases for the diagnosis. While all the professionals contacted sent back some response (at least after follow-up requests), most simply provided general lists of the procedures administered, or sent copies of summary reports prepared for parents and teachers. Therefore, a follow-up structured checklist was developed, based on the few responses that did provide specific information. The checklist categories were: 1) current performance below norm on several formal tests, e.g., medical, psychological, educational, etc. (with published norms, standardized nationally) ; 2) current performance below norm on one formal test (with published norms, standardized nationally) ; 3) current performance below norm on formal tests (without published norms, based on norms internalized from experience and training); 4) current performance below norm on commonly used informal “tests” (with norms internalized based on your experience and training) ; 5 ) behavior manifested during examination below norm (norms internalized based on experience and training) ; 6) performance and/or behavior judged by others to indicate a problem (and you concur) ; 7) performance and/or behavior reported by others, but judgment that this indicated a problem was made by you; 8) performance and/or behavior manifested during several “clinical” sessions (e.g., therapy, remedial teaching, etc.) with you; 9) information regarding client’s “history” seen as causally related to problems and thus as evidence of nature of current problems (e.g., case history, developmental questionnaires, etc.); and 10) other (specify).

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The directions for the checklist indicated: We have attempted to categorize the process by which you arrived at your diagnosis . In the spaces provided please indicate whether you agree or disagree, and what misinterpretations we may have made.

..

If we could not categorize the process, this was stated and the professional was asked to check the categories. Again, in all cases, specifics were requested, including a statement of the information that “pinpointed the problem and led to a diagnosis,” e.g., clarifying comments, copies of test data, reports, etc. For eleven of the 26 youngsters from the original sample, the professionals did not respond to the checklist. (The reasons for not responding were varied; three school district offices indicated they didn’t have the personnel to respond to research reports, three agencies indicated the person who did the diagnostic testing was no longer at the agency, etc.) In the end, after several follow-up requests, there were checklist responses and related material complete enough for analyses on each of fifteen youngsters. These fifteen were then categorized with reference to the bases for assigning the diagnostic label. The first step in this process was to divide the responses into diagnoses based primarily on positive test findings, as contrasted to those based primarily on behavioral observations. Each of these sets of responses was then divided into two groupings. Positive test findings were reviewed in order to differentiate those with a consistent pattern of test and other data pinpointing signs and symptoms indicative of a specific source for the problem from those with a contradictory (mixed) pattern of findings. The behavioral observations were

DIAGNOSTIC CLASSIFICATION

720

Table I PARENTS' REPORT OF NUMBER OF "DIAGNOSTIC" LABELS ASSIGNED TO EACH STUDENT (N=38) NUMBER OF LABELS

STUDENTS

3

6 9 13 7

4

3

0 I

2

divided in terms of those where professional observations were limited to one exam session as contrasted to situations where the professional saw the youngster over a number of therapy or evaluation sessions. RESULTS AND DISCUSSION

Findings from this limited investigative foray are offered here for their heuristic value and because they provide a relevant, albeit modest, example of diagnostic labeling practices. Since procedures for quantifying the findings could only capture a restricted portion of the phenomenon being studied, a number of qualitative observations are discussed in conjunction with numerical findings. Type and number of labels. TABLES 1 and 2 present some of the findings from the parent questionnaire. Even from this small sample, it seems safe to suggest that a very large number of students with learning problems are being assigned more than one diagnostic label. In addition, the findings highlight some of the problems with current classification schemata as applied by professionals in the field; for example, there is relatively little aqreement regarding the label that should be assigned, symptoms and signs used to arrive at

one diagnostic label appear to be common to many other labels, symptoms are used as labels, once a label is assigned it is difficult to know what it signifies other than a child with a problem. Given the emotional correlates of learning problems and the inappropriate behavior usually manifested by youngsters diagnosed as hyperactive, it is interesting to note that only two students were labeled emotionally disturbed. It may be that this indicates that differential diagnosis between problems primarily due to emotional factors and those stemming from other bases can be made satisfactorily, or it may be that diagnosticians find it more acceptable to assign rubrics such as hyperactive, disruptive, educationally handicapped, etc., than to label a youngster as emotionally disturbed. It probably also should be noted that the large proportion labeled educationally handicapped is undoubtedly due to the fact that California uses this designation for special class placement of youngsters with moderate to severe learning and emotional dysfunctions who are at least of average intelligence. This highlights the need for further systematic investigation on the question of the degree to which administrative factors rather than specific diagnostic data actually determine the label a professional decides to assign. Bases for diagnostic labels. With reference to specific bases upon which professionals assigned diagnostic labels. the sample clearly is inadequate and the variables investigated are fairly restricted. Still the findings are suggestive. Perhaps most striking is the finding that only one out of fifteen diagnoses resulted from a consistent pattern of data from tests designed to systematic-

HOWARD S. ADELMAN

72 I Table 2

PARENTS’ REPORT OF TYPES OF “DIAGNOSTIC” LABELS A N D PAIRINGS A M O N G LABELS PAIRINGS AMONG LABELS TIMES USEDs

LABEL LD DYS MBD E H H Y P Learning disabled/ disordered ( I D ) 10 (1)b 4 2 6 3 Dyslexic (DYS) 7 4 ( I ) I 4 2 Minimal brain dysfunction ( MBD) 4 2 1 [ - - ) 3 3 Educationally handicapped ( E H ) 17 6 4 3 ( 3 ) 6 Hyperactive ( H Y P ) 17 3 2 3 6 ( 2 Emotionally disturbed (ED) 2 I Perceptual problemr (PER) 2 2 I I Educable mentally retarded (EMR) I I Slow learner (SL) 2 I Disruptive (DIS) 6 1 3 3 a Labels assigned to 32 students. b Numbers in parentheses show students given just the one label.

ED

-

ally sample the specific bases for learning problems, e.g., data from neurological tests, perceptual and motor tests. In marked contrast, nine of fifteen diagnoses were not based on any positive test findings and the majority of these were based on observational data-primarily the unsystematically gathered and formulated reports of parents and teachers validated by the professional’s observations during one examination session. That is, in these instances, any test data gathered essentially were not indicative of problem areas. In a not untypical example, a pediatrician diagnosed a seven-year-old boy as having a hyperactive behavior syndrome and minimal brain dysfunction based on “short attention span and distractible” behavior manifested during the examination, and reports from the mother and teacher which stated that the boy’s behavior and performance were a problem. “Cursory” neurological findings were found to be

-

-

)

1

- - -

- - - -

PER

(

I

)

_

-

-

-

-

-

I

-

-

I

1

-

-

-

-

-

DIS

-

1

(-1

-

-

SL

2 I

-

(-)

-

EMR

I

3 3

-

- - I (1) -

(-1

normal. Once diagnosed, the youngster was placed on amphetamine medication. He was subsequently diagnosed as educationally handicapped and placed in a special class. Somewhat more disconcerting is the finding that five of fifteen of the diagnoses were arrived at despite contradictory evidence. For example, a nine-yearold boy referred because of “learning problems in school” was diagnosed as learning disabled ( a term which usually implies to others that the youngster has some type of internal dysfunction as the origin of the learning problems). This diagnosis was based primarily on poor reading performance reported by the school (e.g., letter reversals, poor phonetic analysis skills, poor memory) and below normal scores on standardized tests of reading and a “highly significant difference between his Verbal and Performance IQ scores on the WISC-R” (verbal score in the low aver-

722 age range and the performance score in the superior range). This diagnosis was made despite performance at or above norm on the Bender Visual Motor Gestalt Test, the Southern California Sensory Integration Tests, the Wepman Auditory Discrimination Test, and the Illinois Test of Psycholinguistic Abilities. It is interesting to note that in the seven cases where physicians were involved in evaluating the bases for the problems, no abnormal neurological findings were reported even though complete or partial neurological testing was done with five youngsters. In general, in validating that a problem existed, the physicians’ findings stressed case history material, parent and teacher reports of problems, and behaviors such as activity level, lack of cooperation, nervousness, etc., manifested during the physical examination. Other relevant findings.Another point worth emphasizing is the ages at which the youngsters were diagnosed. For nineteen cases where we have enough data from professionals to verify the age at which the first diagnosis was made, the mean age was 8.4 (SD=2.34) with a range of 6.2 to fourteen years. (Current mean age of the yowesters is 14.0, with a range of 7.8 to 17.5.) Adding in seven other cases where parents provided clear age estimates lowers the mean age slightly to 7.8 years (SD= 2.31) with the youngest being five years. These findings show that these youngsters were diagnosed early in their school careers. Such findings are consistent with those from a prediction study carried out by my colleaeues and lo which demonstrated that a large number of learning and behavior problems can be identified as early as

DIAGNOSTIC CLASSIFICATION kindergarten. More importantly, the data from the present study (and the prediction study) suggest that a large proportion of youngsters with learning and behavior problems are being identified by parents and teachers without the need for other screening procedures. In effect, the majority of the professionals in this small study were doing no more than agreeing that the referral problem existed and then assigning a label consistent with the referral problem or with school administrative requirements for sanctioning special programs. The current mean age of the 26 youngsters (on whom we had the information to arrive at an average age at first diagnosis) is 14.1 (SD=2.4) with a range from 7.8 to 17.8 years. This is an indication of how long (over six years, on the average) some of these youngsters have lived with diagnostic labels, special programs, etc., and how difficult it is to correct learning and behavior problems that are severe enough to be obvious to parents and teachers during the first years of schooling. What is not clear, of course, is for whom the diagnostic labels were correct. Where they were correct, it may have been indicative of problems so severe they could not easily be remedied. However, where they were invalid, the diagnosis and special programs themselves may have lead to self-fulfilling prophecies and a “snowballing” of problems. Finally, it is worth commenting on the usefulness of the professional reports received. As is common practice, this sample of clinical material contained not only the diagnosis, but general treatment recommendations. Yet, as the first responses from the professionals included in this study demonstrated, the report contents were inadequate for determin-

HOWARD S. ADELMAN

ing the bases for the diagnoses, much less for programming recommendations. Furthermore, even with the addition of clarifying material, the reports that suggested specific programming recommendations, such as perceptual training, medication, and so forth, not infrequently appeared to be based more on the assessor’s treatment predilections than on the adequacy or validity of the specific assessment data. In addition, almost every report contained a great deal of unnecessary and often misleading and confusing material (extensive summaries of developmental histories, family status, peer relations, specific test scores and responses, etc.) without any clarification of how such matters might be causally related to the referral problems or diagnosis or how they might rule out some factor as a cause. There were several instances where a total test score was reported which was clearly at or above norm for the youngster’s age group without this fact being stated, while at the same time a missed item from the test was presented as an example to support the conclusion that the area tested was a problem area for the student. It was particularly ironic to find extensive discussion of performance deficiencies on reading achievement tests in reports that were sent back to the teacher who had referred the child for assessment in the first place because of extensive deficiencies in reading noted in the classroom. It was also ironic to find indications that the child was uninterested and manifested avoidance motivation in taking the diagnostic tests (e.g., “X did not want to perform the tasks requested.”), yet find that test scores were still interpreted as valid indices of developmental capabilities (as contrasted to current motivational status).

723

The selective omission of statements regarding strengths, even when test performance was superior, was a graphic demonstration of the prevalence and impact of pathological biases that appear to permeate such assessment activity, thereby undermining the great potential value of such activity in identifying unwarranted attributions of causality. Despite these deficiencies, a major strength of the various diagnostic assessments was that they allowed for the validation by an “expert” of the presence of the problem and the need for special attention to correct it. CONCLUSIONS

As even these cursory findings suggest, major investigations of contemporary practices related to diagnostic classification are needed. Such investigations can greatly enhance our understanding of the validity and implications of current classification schemata being applied to persons who manifest learning and behavior problems, and can provide an empirical basis for revising or replacing current categorizations as needed. As stated at the outset, valid classification is an indispensible activity facilitating (and, by implication, possibly hindering) clinical and research practices. The question explored here has been how valid is contemporary classification activity related to learning and behavior problems? The findings indicate that the diagnostic labels attached to the sampled youngsters clearly did not specify the cause of their problems, valid treatment procedures, severity of problem, prognosis, and so forth; in several instances, the diagnoses (e.g., learning disabled, hyperactive) seemed merely to take the place of referral terminology (e.g., reading difficulties, poor school skills, be-

DIAGNOSTIC CLASSIFICATION

havior problems). In current practice, it seems clear that a wide range of labels are used in classifying individuals who manifest such problems. For example, the diagnosis of learning disabilities (LD), as defined in federal legislation (PL 94-142), is intended to differentiate, from among all those youngsters who manifest learning problems, that subgroup whose problems stem from a cerebral dysfunction that has resulted in a severe discrepancy between achievement and intellectual ability (excluding those whose problems stem primarily from visual, hearing, or motor handicaps, mental retardation, emotional disturbance, and environmental disadvantage). To date, there is no satisfactory evidence that such differential diagnosis is being made reliably and validly on a large scale and there is some evidence, supported by the present study, suggesting it is not. Thus, for direct clinical purposes, the classification activity in this area appears to be quite inadequate. At the same time, the labels appear to play an important role in justifying the application of specialized interventions, which usually are administratively available only after diagnosis is made (e.g., drugs, special class placement, special funding). Thus, in the cases investigated here, the function of the assessor was that of a gatekeeper, and assignment of a diagnostic label opened the gate to interventions not readily available to persons with “ordinary” learning and behavior problems. Unfortunately, the inadequacy of the diagnostic classifications being made contributes to and raises serious concerns regarding what amounts to a prevalent and widespread tendency, related to learning and behavior problems, to administer unvali-

dated procedures prematurely, such as massive screening programs for diagnosing L D in kindergarten and earlier,3 or large scale, relatively uncontrolled prescription of stimulant drugs for those diagnosed as hyperactive.6 For research efforts that involve youngsters diagnosed as LD, hyperactive, or some related label, these questions of diagnostic criteria are profound. Even when two studies purport to be sampling the same population (e.g., hyperactives), they may have selected children who differ significantly with reference to a number of critical dimensions (degree of activity, degree of school-related learning problems, etc.). At the same time, studies purporting to sample different populations (e.g., minimal brain dysfunction vs. emotional disturbance) may be taking some subjects from the same population or even from another group. Thus, limitations of current diagnostic procedures make it very difficult to identify homogeneous groups of subjects (with regard to critical variables), thereby almost guaranteeing that the youngsters in any given sample will differ as to the source of the problem and the “syndrome” manifested. This, of course, limits analyses and generalizations of findings. Valid classification is a critical step in advancing knowledge related to learning and behavior problems. It is time for a concerted effort by researchers to validate procedures that can result in accurate diagnostic classification with reference to these problems. As the evidence accumulates indicating that widely used diagnostic procedures produce errors, confusion, and mystification, it is necessary to consider new approaches. For example, a sequential and hierarchical strategy has been proposed as a

HOWARD S. ADELMAN

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way to filter out, through personalized instruction, those persons whose learning and behavior problems do not stem from cerebral dysfunctioning,'* and to investigate, systematically, the brain-behavior relationships of the remaining individuals.lE Other researchers focusing on LD also have suggested some type of sequential screening 2 4 or ongoing hypothesis verification 25 as the process by which individuals with cerebral dysfunctions might be identified in the larger pool of persons manifesting learning problems. Such strategies not only may lead to more accurate diagnosis of LD, but also may distinguish several other significant subgroups of persons manifesting learning problems-possibly including relevant subgroups of LD. More generally, then, in addition to gathering data on contemporary diagnostic practices, empirical investigation is needed to explore alternative strategies for achieving valid diagnostic classifications. Related to such investigation is the need for considerable conceptual activity to help resolve the major theoretical and ethical issues involved in the development and application of classificatory schemata. REFERENCES 1. ADELMAN,

H.

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AND STEGER, H. 1972. Prescriptive and consultative approaches to psychological evaluation. Professional Psychol. 3:105-109. 9. CRONBACH, L. 1975. Five decades of public controversy over mental testing. Amer. Psychol. 30: 1-14.

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meaning of psychodiagnosis. Amer. Psychol. 26: 160-167. 12. HAYWOOD, H. 1971. Labeling: efficacy, evil and caveats. Presented to Joseph P. Kennedy Jr. Foundation International Symposium on Human Rights, Washington. 1 3 . ~ o e a s ,N . 1975. The Futures of Children: Categories, Labels, and their Consequences: Report of the Project on Classification of Exceptional Children. JosseyBass, San Francisco. 14. MERCER, J. 1972. Labeling the Mentally Retarded: Clinical and Social System Perspectives on Mental Retardation. University of California Press, Berkeley. 15. MEsSICK, s. 1975. The standard problem: meaning and values in measurement and evaluation. Amer. Psychol. 30:955-966. 16. MISCHEL, W. 1968. Personality and Assessment. John Wiley, New Ycrk. 17. PHILLIPS, L. AND DRACUNS, J. 1971. ChSSification of the behavior disorders. I n Annual Review of Psychology, Vol. 22, P. Mussen and M. Rosenzweig, eds. Annual Reviews, Palo Alto, Calif. 18. ROURKE, B. 1975. Brain-behavior relationships in children with learning disabilities: a research paradigm. Amer. Psychol. 30: 9 11-920. 19.

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DIAGNOSTIC CLASSIFICATION teristics of school labeled learning disabled children. Except. Child. 43:352-357. 22. STRUPP, H. AND HADLEY, s. 1977. A tripartite model of mental health and therapeutic outcomes with special reference to negative effects in psychotherapy. Amer. Psychol, 32: 187-196. 23. SUNDBERG, N . 1977. Assessment Of Persons. Prentice-Hall, Englewood Cliffs, N.J. 24. WADE, T. AND BAKER, T. 1977. Opinions and use of psychological tests: a survey of

clinical psychologists. Amer. Psychol. 32: 874-882. 25. WEDELL, K. 1970. Diagnosing learning disabilities: a sequential strategy. J. Learn. Disabil. 3:311-3 17. 26. WISSINK, J., C . AND FERRELL, W . 1975. A Bayesian approach to the identification of children with learning disabilities. I. Learn. Disabil. 8:158-166, 27. ZICLER, E. AND PHILLIPS, L. 1961. Psychiatric diagnosis: a critique. J. Abnorm. SOC. Psychol. 63:607-618.

For reprints: Dr. Howard Adelman, Department of Psychology, University of California, Los Angeles, Calif. 90024

Diagnostic classification of learning problems: some data.

Amer. 1. Orthopsychiat. 48(4), October 1978 DIAGNOSTIC CLASSIFICATION OF LEARNING PROBLEMS: Some Data howard S. Adelman, Ph.D. University of Califo...
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