Adult SLD Certification in Real-world Settings: Too Late or Still Valid

Abstract

Specific learning disability (SLD) is a neurodevelopmental disorder recognized as disability in India. SLD assessment in adults is challenging due to the absence of childhood records, overlapping conditions, and limited adult-specific tools. This article discusses practical assessment challenges through hypothetical case scenarios and emphasizes the need for clearer guidelines.

Specific learning disability (SLD) is a lifelong neurodevelopmental condition that affects core academic skills due to deficits in writing, reading, spelling, or mathematical calculations, despite average intelligence. ¹ The Rights of Persons with Disabilities (RPwD) Act, 2016, recognizes SLD as a disability that qualifies for official certification. The 2024 RPwD gazette states that screening for SLD should begin by Class 3 or at 8 years of age. Diagnosis of SLD in children carries certain disability benefits for children in school exams. After 18 years of age, adults with SLD do get benefits under the disability quota in college entrance exams for academic courses, and there is also an additional at least 4% reservation in government jobs. Here is the importance of obtaining an authentic certification following a detailed evaluation by a trained professional. As per the guidelines, the board that certifies SLD shall include a pediatrician/Pediatric neurologist/Psychiatrist and a clinical psychologist for a detailed SLD assessment. ²

The prerequisite for SLD diagnosis is Intelligence Quotient (IQ) 85 or more, No vision and /or hearing impairment which are likely to affect learning, no emotional and behavioral disorders mimicking SLD, Presence of adequate opportunity for learning with proper motivation, The child is functioning at three standard deviations below the current class on National Institute of Mental Health and Neuro Sciences (NIMHANS) battery or their Grade Level Assessment Device (GLAD) score is below 40%, for the child’s current class level. Reassessment of the child for repeat certification should be carried out during Class X and Class XII, if required. The certificate issued at 18 years or more will be valid lifelong. ²

Globally, the Diagnostic and Statistical Manual of Mental Disorders (DSM-5) estimates the prevalence of all learning disorders at around 5%–15%. Indian studies show a much wider range, with prevalence ranging from 2% to 31%. In systematic reviews, the pooled prevalence of learning disabilities among Indian children and adolescents is estimated to be 8%–11%.^3,4

Despite its high prevalence, SLD remains largely under-addressed and under-diagnosed. Many children are missed from the consultation and thorough assessment during the school years, which becomes a particularly significant issue in the Indian context, where factors such as a shortage of trained professionals, social stigma, language barriers, and limited awareness hinder early identification. These gaps underscore the need for strengthened efforts in teacher training, systematic screening, and societal awareness in the country. As a result of these challenges, many individuals approach the medical system directly in adulthood. These children are often identified at a later age or in higher grades, after experiencing prolonged academic difficulties and emotional distress, leading to missed opportunities for early intervention. ⁵ Although early identification of learning disabilities is essential to ensure timely and effective intervention.

Assessing and certifying SLD in adults becomes even more complicated for professionals, owing to past school records, early assessments, or clear documentation of childhood difficulties, which can make the process challenging. Few authors highlighted challenges in SLD certification in general, including language barriers in assessment, poor awareness among parents and teachers, lack of research, lack of adult-specific tools, and shortages of trained human resources, etc. ³ While existing literature focuses on children with SLD, this article addresses the less explored area of adult SLD assessment and certification. It also discusses unique challenges such as comorbid conditions, retrospective diagnosis, and malingering, using hypothetical case scenarios to illustrate real-world practical issues.

Case Scenarios

We are discussing the case-wise key issues in adult SLD assessment using the following hypothetical scenarios:

Case Scenario 1

A young male student presented alone to seek a disability certificate for SLD. He has a documented history of visual impairment, likely amblyopia, since childhood, for which a 30% disability was previously certified by the ophthalmology department. Anticipating a cumulative disability exceeding 40%, he approached the psychiatry department to include SLD-related disability.

The patient had no prior psychiatric evaluation or consultation. When requested to attend with his parents for childhood history, he declined, stating that his parents are illiterate and would be unable to comprehend the assessment process, and insisted on proceeding with the SLD evaluation independently.

During assessment, the patient demonstrated an inability to answer simple questions and provided inconsistent responses to more complex queries, raising suspicion of intentional misrepresentation. A subsequent malingering assessment was conducted, which yielded positive results. The findings were communicated to the patient, who continued to assert that he had SLD and expressed dissatisfaction with the refusal to issue a certificate.

Key issues in this case:

Lack of childhood psychiatric assessment or consultation.

Absence of an informant for collateral history.

Coexisting visual impairment potentially impacting learning ability.

Evidence of deliberate errors during assessment indicates possible malingering.

The RPwD gazette 2024 emphasized that the initial evaluation for SLD should be conducted by a pediatrician/pediatric neurologist and a psychiatrist. However, in cases of adults presenting with SLD, it also requires assessment by a physician, which is not mentioned in the gazette. Moreover, in the above case scenario where visual impairment is impacting learning, the gazette does not include an ophthalmologist on the team, and specific guidelines for quantifying and attributing learning problems to vision versus SLD have not been specified. Considering the patient’s higher educational degree and upcoming job reservation, it is a lucrative and easy way to obtain the certification to avail such benefits. However, all these issues pose a challenge for professionals, with no recourse to the ministry or the gazette.

Case Scenario 2

A middle-aged male presented to the psychiatry department for consultation regarding his 9-year-old son’s poor academic performance. Following the assessment, the child was diagnosed with SLD and was issued a disability certificate.

During subsequent visits, he disclosed that he himself had experienced similar academic difficulties since childhood, including persistent challenges with reading, grammar, and writing. Despite these difficulties, he completed his postgraduate studies and is currently pursuing a higher degree. After learning about government job reservations for individuals with SLD, he requested a disability certificate.

He also reported a history of social anxiety since adolescence, for which he had been prescribed SSRIs and benzodiazepines. He strongly insisted on receiving an SLD certificate; however, it was explained to him that treatment for his anxiety would need to precede certification. Meanwhile, he attempted to obtain an SLD certificate from another medical college, but the attempt was unsuccessful. Following his persistent requests over 6 to 8, a comprehensive assessment using the NIMHANS battery was finally conducted, which confirmed a diagnosis of SLD.

Key issues in this case:

Absence of prior psychiatric or learning disorder assessment during childhood.

Evident motivation to obtain disability certification.

Coexisting conditions, including social anxiety, may have contributed to learning difficulties.

Compensation and masking happen over time, which further complicates the real-life difficulties faced by the individual.

Lack of awareness among schools, colleges, and parents in the early years led to delayed treatment-seeking in this case. However, such scenarios have not been hypothesized by the ministry and gazette; therefore, this decision largely remains dependent on the clinician’s judgment. A trained clinician does feel hesitant in such cases where no prior assessment record is available, and the patient survived the school and college years and progressed to a higher university degree. The lack of standardized assessment tools for adults further adds to the confusion about the final impressions in this case. However, the patient’s struggle was evident in his performance, including repetitive writing of the thesis and doing academic work by listening to audio/video learning material. Overall, the clinical interview, multiple observations, and assessment findings support the diagnosis of SLD, but the process remains a roller coaster ride for both the patient and the clinician.

Case Scenario 3

A young male with a known history of seizure disorder was referred from the neurology department for evaluation of cognitive functioning. SLD. His last documented seizure occurred at the age of 15. The case was reviewed by a psychiatrist and a clinical psychologist, where the primary challenge identified was differentiating the impact of cognitive deficits related to the seizure disorder from a distinct learning disability. Assessment of the cognitive skills in the light of the history of seizure and deficits in current socio-adaptive functioning was done. Findings revealed an IQ/SQ of 84, thus suggesting borderline deficits in intellectual/ socio-adaptive functioning.

Key issues in this case:

No prior psychiatric or developmental assessment during childhood addressing learning difficulties.

The presence of a seizure disorder, which may contribute to cognitive and learning challenges, complicates diagnostic clarity.

In this case, the evaluation by the neurologist for current deficits was warranted, but this is not mentioned in the gazette. Though borderline deficits suggest 25% disability, it does not account for any disability benefits in the real world, but the struggle of the patient and family is real. This has been debated many times before, but there’s no way out for these patients. It was challenging to make the father understand that getting certification will not solve their problem if they want to use it for a government job reservation, as borderline deficits would definitely hinder independent work performance.

Challenges in the Assessment and Certification of SLD in Adults

We observed several key challenges in the assessment and certification of SLD in adults based on our experiences in our setting:

Lack of Adult-specific Tools

Historically, the primary issue was the absence of diagnostic tools specifically designed for adults with SLDs. The existing guidelines and tools were primarily developed for assessing children. The gazette notification stated that the NIMHANS battery, or GLAD, shall be administered across all ages until new scales are developed and validated for older children and adults. ² Another challenge is that approved tools like the NIMHANS battery and various IQ tests are copyrighted. There are no clear directives on their procurement or funding mechanisms. ⁶ Therefore, it is essential to develop a new, adult-specific assessment scale to ensure accurate evaluation and minimize errors in certification.

There are limited assessment tools for adults. However, in Western countries, norm-referenced tests (NRTs) of academic achievement are commonly used in adults to assist the diagnosis of SLD. The tools are used to make decisions on interventions, educational planning, and eligibility for special education services for individuals with learning disabilities. ⁷ Widely used assessment tools include the Woodcock-Johnson IV Tests of Achievement (WJ IV ACH), ⁸ Wechsler Individual Achievement Test-4 (WIAT-4), ⁹ Wide Range Achievement Test-5 (WRAT-5). ¹⁰ An adapted Indian version of the WRAT-5 is available for children aged 6–19 years, but there is limited independent evidence of its psychometric validation in Indian settings. It is available in English as well as four Indian languages: Hindi, Marathi, Kannada, and Tamil. ¹¹

Permanent Certification Versus Remediation

Assessing adults for SLD and providing certification has lifelong validity, which cannot be reversed or checked at any point, further raising concerns about ensuring a detailed assessment to avoid any discrepancy or misdiagnosis.

Research evidence and clinical judgment of the last two decades highlight the role of intensive remediation that can significantly reduce the symptoms of SLD, enabling students to succeed academically, pursue higher education, and become productive members of society, which can make it challenging to determine whether the person still meets the criteria for a disability. Herein, the collaborative intent is always remediation- or treatment-oriented rather than disability-certification-oriented. In contrast, real-world practices have only encouraged SLD certification owing to the tangible benefits of various reservations. Internationally, the United Kingdom provides extra time or modified papers with reassessment every 4 years, while Singapore offers extended time, separate rooms, larger print, and exam exemptions. These examples illustrate that targeted support can improve learning outcomes and functional abilities without necessitating a permanent disability certification.^6,12

Language Problem

The majority of rural patients and adults have a Hindi-speaking background, which raises concerns about the language of the assessment tool. The majority of the tools available are in English, so translating the items into other languages invalidates the whole assessment.^6,13 Therefore, there is a need to develop a multilingual simple assessment tool suitable for the Indian context.

Lack of Past Assessments

In the two case scenarios described above, the individuals visited the Psychiatry OPD for the first time solely to seek an SLD certificate. They had never seen a psychiatrist or any healthcare professional for their childhood learning difficulties, and they also did not have any records documenting these problems. Individuals presenting for learning assessment without a prior SLD certificate pose a challenge due to inadequate school records and the absence of detailed teacher observations. ¹⁴

SLD Mimics

The guidelines state that SLD should not be diagnosed when conditions that mimic SLD are present, but they do not clearly explain what these mimics are. Since disorders like ADHD, Anxiety, Depression, Autism, and others can occur along with SLD, clearer guidance on what qualifies as an SLD mimic would help make assessment and certification more accurate. Overlapping symptoms with psychiatric and neurodevelopmental disorders further make it more confusing and challenging.

Lack of a Multidisciplinary Team

The gazette states that SLD assessments should be conducted only by a pediatrician and a Psychiatrist. At the same time, it also mentions that children should not have vision or hearing problems that affect learning, yet it does not include ophthalmologists or ENT specialists in the assessment. ¹⁵ They can more accurately identify which conditions might interfere with learning. Therefore, a proper multidisciplinary team—consisting of a psychiatrist, a child or clinical psychologist, a pediatrician/pediatric neurologist/physician, an ophthalmologist, and an ENT specialist—is essential for an accurate SLD evaluation.

Retrospective Diagnosis

Late presentation is most challenging in adult cases. Adults develop compensatory strategies and learned coping mechanisms. Existing standard tests are also not appropriate for adult assessment. It also makes it difficult to determine developmental onset—a core diagnostic criterion for SLD.

An Individual with Borderline Intelligence

They face a gap in the RPwD Act, as SLD is diagnosed only with an IQ above 85. The benefit of intellectual disability (ID) is available to individuals with IQ scores below 70. Those with IQs between 70 and 85 struggle academically but receive no benefits. ⁵ Similar issue has been highlighted in the third case scenario.

Gap Between Policy Intent and Real-world Assessment

The RPwD Act, 2016, and the University Grants Commission (UGC) both recognize SLD as a benchmark disability. In 2022, UGC issued the “Accessibility Guidelines and Standards for Higher Education Institutions and Universities,” which promote inclusive education for persons with disabilities through academic accommodations, examination support, and accessible learning environments. ¹⁶ However, access to these benefits is dependent on obtaining formal certification under the RPwD provisions, which are largely child-centric. Considering the hidden nature of disability and varied levels of difficulties, many adults often become aware of their learning difficulties after entering higher education, and then they seek certification. However, the certification process for adults itself has multiple structural, procedural, and resource-related barriers. These include delayed diagnosis, lack of standardized adult assessment tools, shortage of trained professionals, lack of prior records, and limited access to multidisciplinary evaluation teams, thus leading to a high risk of rejection during the certification process. Consequently, despite UGC guidelines offering extensive support for students with SLD, the practical implementation of RPwD certification frameworks creates a significant policy–practice gap, leaving many eligible adults unable to avail themselves of these benefits. Moreover, guidelines in place do not ensure the implementation at Higher Education Institutions (HEIs) where they have yet to adapt curricula, teaching methods, or assessments to support adults with SLD. ¹⁷

Lack of Awareness and Stigma

Parents and teachers lack awareness, which remains a major barrier to identifying SLD. These children are often labeled as “slow learners” and may experience harassment or bullying due to poor academic performance, which can impede their learning and exacerbate their difficulties. Although certification is required to access exemptions and concessions during schooling, assessment procedures vary across educational boards and are often misaligned with RPwD guidelines. ¹² The 2024 gazette mandates that teachers interview parents to assess their motivation before referring a child for further evaluation if the child is found to be screen positive. However, parents may be reluctant to seek consultation due to fear of stigma or being perceived as having a child with a mental illness. ⁵ Stigma in adults with SLD is largely internalized, involving issues related to their self-esteem, getting labeled as “lazy/incompetent” at work, along with discrimination related to assigned job responsibilities. Adults with SLD often feel ashamed to disclose their difficulties due to fear of being judged as less capable. Fear of discrimination, job loss, and negative labeling discourages many adults from obtaining certification or seeking accommodations. ¹⁸

Conclusion

Assessing and certifying SLD in adults is difficult for mental health professionals, especially when adults come for evaluation for the first time, only to obtain a certificate. Challenges include the lack of standardized assessment tools, gaps in the guidelines, the absence of other specialists, and the possibility of external motives for obtaining disability benefits. To improve the process, all stakeholders, teachers, principals, healthcare professionals, and psychologists and psychiatrists should receive regular training on SLD assessment and certification. Frequent meetings between relevant authorities and policymakers are also needed to update rules and streamline the certification process. It has been noted that demand for SLD certificates has surged disproportionately in urban areas, underscoring the urgent need to establish uniform National Guidelines for Adult SLD Assessment & Certification to prevent misuse.