Critical Review of Use of Medical Versus Social Model for Identification of Learning Disabilities

Abstract

The process of identification of specific learning disability (SLD), in India, is dominated by the medical model with strong emphasis on an IQ score of 85 and above, as an important inclusion criterion. In addition, there is minimal emphasis on tracking learning history for quality interventions. Only parent reports that they have been teaching the child and child’s attendance of a formal school since the beginning of their scholastic journey are taken as indicators that the child has been taught the foundational skills of reading, writing, and maths but has failed to show mastery. The focus of the research paper is to critically review the medical model and social model to be able to make suggestions of best fit. The perspective is to be able to look at learning disability from the point of functionality and bring forth the options that can assist specific cases of scholastic underachievement. The present paper outlines the problems with following the IQ score driven, medical model while addressing an educational problem. Further, suggestions are made toward creating a social, problem-solving approach toward identification of SLD that will focus more on teaching toward closing of scholastic lags and identification of specific needs and supports that learners need to successfully complete their schooling, with confidence and pride.

What are Learning Disabilities?

Learning disabilities (LD) are characterized by inability to master foundational academic skills, specifically in the areas of reading, writing, and maths. These inabilities are manifested in the formal school settings, when learners are not able to acquire the foundational scholastic skills, despite quality interventions, and in the absence of any other interfering conditions, such as intellectual deficit, mental illness, or cultural and linguistic disadvantage.

The current medical nomenclature uses the terms developmental learning disorders, ¹ and specific learning disorder ² when learners show significant and persistent scholastic lags. The current legal framework in India uses the term specific learning disability (SLD) ³ to identify this phenomenon. Following consistency with the Indian systems, the current paper will use the term SLD to refer to this phenomenon.

SLD is grouped as a neurodevelopmental disorder, ⁴ that is, the deficits in language, and scholastic performance are related to deviations in brain development. At the same time, it is diagnosed through performance-based measures of academic achievement and does not involve the study of brain scans. Learner’s performance on various standardized psychometric tests is compared to the specific age-based norms, generally established separately for each nationality.

Along with the learner’s performance on various psychometric instruments, clinicians also consider aspects of overall biological markers, sensory functioning (such as hearing, vision), assessment of any comorbidities, developmental, family, and schooling history of the learner. The estimates of accounts shared by the family members are taken to rule out that the learner has received adequate teaching and learning experiences in the language which is used as the medium of instruction in the school. The clinicians also consider the absence of impact of any psychosocial stressors, to explain the significant and persistent scholastic lag being exhibited by the learner. While these are a few essentials during the process of evaluation of a case, there is subjectivity that is required for evaluation of the cases of SLD. Each case needs to be evaluated on an individual basis before creating/designing the required interventions and therapy. In Indian context, culture could be a significant variable as it would influence learning of language and thereby have an impact on academic performance. The study conducted by García & Dominguez ⁵ found that when students experience academic or behavioral difficulties, examining their learning experiences from an ecological perspective provides a much broader understanding of the relationships between culture, learning, and academic performance. The value of the systems approach to viewing culture is that it points to the limitations of focusing on a single aspect of the interactions between culture and academic performance. As we move to articulate an integrated, inclusive educational system, we must develop programs and services that are responsive to the diverse sociocultural and linguistic backgrounds of the students and families we serve so that all children participate in equally meaningful educational experiences.

Medical Model Versus Social Model for Specific Learning Disability

In schools, children who lag in their ability to read, or write, constantly stay in a context of disadvantage. They are not able to access all the learning opportunities that their educational setting offers. These learners depend on the teachers and other school personnel to make educational experiences accessible for processing. For example, what is written in books or blackboards or question papers should be read out aloud for the learner to know the information. The absence of such an accommodation will keep the affected learners unable to make progress.

When operating in a medical model, ⁶ such accommodations are not provided until the learners receive a formal diagnosis. By nature of a medical model, the gaps in the learners’ ability to read or write are seen because of the inability intrinsic to the learner, making the learner feel inherently inferior and incapable of growth. The medicalized model also puts important educational decisions in the hands of doctors and specialists, ⁷ who are likely far removed from the educational setting.

In contrast, a social model approach to disability would look at the removal of barriers in order to increase accessibility of resources. ⁸ Within the context of SLD, a social model approach would emphasize making educational provisions that would bring learning experiences within the reach of the learners in their natural school environment. ⁷ Thereby the social model becomes a better fitment for certain disability conditions. The focus is on interventions and facilitation and not just mere identification and diagnostic labeling. The social model enables to formulate the remedial process and progress.

How Does a Medical Model Do Injustice to Young Learners?

History of SLD, in many parts of the world, has witnessed a shift from the medical model, where single point of data collection as a measure for determining SLD has been discontinued for almost 2 decades. ⁹ Single point of data collection seems akin to administering blood tests and bodily scans to identify the presence or absence of biological markers. In case of identification of SLDs, standardized psychometric tests are used as single point measurement of intelligence (IQ) and academic achievement. In India, an IQ score of 85 is used as a cutoff marker for making the diagnosis of SLD. ¹⁰

The use of IQ score as a diagnostic marker for SLD has been deemed problematic for many reasons.^11,12 One of the crucial reasons cited is that IQ tests use measures of verbal ability, which as a cluster is an area of significant difficulty for people with SLDs, leading to disproportionately lower IQ scores. In other words, intelligence and academic achievement have not been seen as independent and the presence of SLD affects IQ scores. Therefore, if a minimum IQ score of 85 is used as a needed criterion for identification of SLD, there is already a confounded group of children who will have a double disadvantage and would never receive services and accommodations offered to people with SLDs.

What Are Possible Alternatives?

A solution to this problem is available when using diagnostic guidelines forwarded by the World Health Organization; instead of using IQ scores as an inclusionary or exclusionary criterion, decision-makers are guided to rule out the presence of intellectual disability (which is more than just IQ scores but also includes daily living functioning) before estimating academic achievement with respect to age or grade level. ¹

Another model that is comprehensive, based in the education system, and moves far from one-point testing as the identification procedure for SLD is the response-to-intervention model (RTI). ¹³ This model uses a problem-solving and instructional approach to encompass prevention, identification, and intervention for SLD. In this model, the emphasis has been placed on providing learning opportunities through levels of intensity (whole class, small group, and individual instruction) and, using these instances as part of comprehensive assessment points for possible identification of SLDs. In other words, under the RTI framework, the focus of educational agencies expanded from mere identification of SLD and placing these students in special education, to providing necessary support that learners needed to make academic gains. ¹⁴ In this light, the RTI model moved the process of detection of SLD within the domain of a social model of disability and away from the medicalized model.

Shifting from the medical model of SLD also changes the language we use while in the process of identification of the disability; instead of looking for children who are learning disabled, we start looking for children who are struggling to make academic gains. ⁹ Once we diligently start scanning for children who are academically lagging, we put educators (who are experts in teaching the key skills of reading, writing, and mathematics) in-charge of looking for possible ways to enable learning, instead of medical doctors who were never trained to teach these critical skills for school success. When school systems become in-charge of the process of identification of SLDs, we also can start the process of intervention early enough in a child’s learning history so that either we are in a position to close the learning gaps or to understand the kind of support that they need to succeed at school. ¹⁵

In this framework, clinical testing would be one piece of data to support or refute the probable presence of SLD, not the only piece. By the time a learner would reach the stage for being tested by a clinician, the school system would already have enough information about what the child’s core struggles are, how have they responded to instruction, what kind of instruction methods have been used, what are the important factors interfering with their learning process, and what kind of supports and accommodations bring out the best potential of the learner. In the medical model, all these pieces of information are largely absent or overlooked, and the one-time testing performance is taken as evidence of a child’s potential to acquire skills of reading, writing, or maths. Along with the medical model, we need to incorporate a framework that focuses on identification and formulation of the required intervention and therapeutic process, medical model does not suffice. Thus, it is essential to establish usage of not just medical models rather social models, such as RTIs to be incorporated.

National Education Policy of India (NEP, 2020) seems to have already moved in this direction by proposing that learning levels of all students, including those who would have dropped out of the school system, should be tracked and students should be given appropriate opportunities to catch-up if they have lagged. ¹⁶ The new policy recognizes not just disabilities but a wider range of groups that are grossly underrepresented in the existing educational systems, including those based on gender identities, sociocultural identities, geographical locations, and socioeconomic conditions. Thus, new social group called Socio-Economically Disadvantaged Groups (SEDGs) has been created. The policy bases most of its objectives on creating inclusivity around these groups. ¹⁷ These groups have higher dropout rates and the NEP 2020 recommends a series of policies and schemes such as targeted scholarships, conditional cash transfers to incentivize parents to send their children to school, providing bicycles for transport that have worked in the past to increase enrolment, to create more representation. The fact stated facilitates the social model of SLD, subtly we are moving toward a shift and are realizing the essence of the social model and necessary changes required in the education system.

Components of Alternative Approach to Identification of Learning Disability

Once we start working from the lens of the social model framework to address the problem of SLD within our education system, our foremost emphasis becomes modification of the instructional environment or settings in ways that will facilitate creation of favorable learning opportunities,^18,19 which in turn starts a cycle of prevention and identification of needs, rather than waiting for failure to emerge and then to treat it.

Modification of instructional environments that would flexibly create optimum learning opportunities would start with teacher training and information about the best practices for teaching key academic skills of reading, writing, and mathematics. ²⁰ Ongoing training, feeling of competence in addressing individual differences among learners and systemic support are important aspects when creating learning environments that will address the needs of all learners, including those who show steep lags. ²¹

Availability of varying intensity of interventions is another aspect of creating learning environments that maximize learning opportunities. Adjusting group size and duration of instruction are some variables that can affect the intensity of learning opportunities provided to each learner. ²² The RTI frameworks have suggested provisions of multitiered systems that include instruction in large groups or whole classes, smaller groups, and one-on-one settings, where it is presumed that one size would not meet needs of all learners and proactive provision of alternative intensities would ensure needs of different learners be met. ¹⁴

Continuous monitoring and screening ²³ for learners who are not showing progress and possibly need more intense and differentiated teaching would be another crucial component. The process of identification, thus, becomes focused on identifying which learners need modified instruction so that they can reach mastery^24,25,26 in basic literacy skills ²⁷ to a level that enables them to competitively complete their academic journeys, without erroneously declaring them incapable of learning these skills; one of the shortcomings of the medical model. ²⁸

Multiple data points that track learners’ responses to evidence-based interventions. When teaching learners who show lags in academic skills, training in specific pointed areas can support and boost growth exponentially.^29,30 For example, the Reading Panel, conducted in the United States, in 2000, pointed to 5 key indicators for assessment as well as instruction for reading skills as phonemic awareness, phonics, fluency, vocabulary, and comprehension skills. ³¹ Identification of what kind of support learners continue to need, in spite of high quality instruction, then becomes the identification system for SLDs.^32,33

Conclusion

The medical model of SLD has not demonstrated learner-centered systems of identification. Instead, these increase stigma and move learners away from the educational settings. The medical model tends to focus more on the cause-effect of the situation rather than working toward the remedy or change that can benefit the concerned individual and family. The lack of developing effective intervention that is based on individual and specific needs causes the model to not be effective with SLD cases. At the same time, the social models have shown promise in creating learning opportunities for young learners by removing barriers and putting their teachers in charge of monitoring interventions and the learning process. Not only do these models reduce stigma, they also ensure that school systems take a proactive approach toward identifying needs of the learners and create instructional environments informed by best practices in teaching of foundational academic skills. The social model is thus more individual centric and understands the needs and engagement that is essential at a subjective level. This serves the purpose of being more effective and outcome oriented with cases of SLD and scholastic underachievement, in general. While NEP 2020 has tried to address various issues, there are existing issues and concerns that remain unanswered. The NEP is far from addressing core issues of inclusivity and conversations that are missing in the existing schooling systems. We have stated a process of identification yet no one answer may be the best fit, it is only after implementation and application will we be able to identify and move our way forward.