Time to Take a New Look at Specific Learning Disabilities
Specific Learning Difficulties is included as a category of disability in Hong Kong's newly released Rehabilitation Programme Plan 2007. Implications of the inclusion, rights of the persons concerned under the Disability Discrimination Ordinance and relevant international treaties, obligations of the Government and Hong Kong as a whole, and role that medical practitioners can play to help fulfill these obligations are discussed in this article.
Keyword : Dyslexia; Specific learning disabilities
In early 2005, the Rehabilitation Advisory Committee (RAC) commenced a review of the Hong Kong Rehabilitation Programme Plan (RPP). The then Health, Welfare and Food Bureau of the HKSAR Government set up a RPP Review Working Group in March of the same year, comprised of representatives from relevant government departments and stakeholder groups, to conduct an examination of existing rehabilitation directions and services. A new RPP was finally released in 2007.
On disability types for people requiring rehabilitation services, the new RPP proposes, on top of the former eight categories of disability, including autism, hearing impairment, intellectual disability, mental illness, physical disability, speech impairment, visceral disability and visual impairment, to add two new categories, namely Attention Deficit/Hyperactivity Disorder and Specific Learning Difficulties (SpLD).1 For the purpose of this article, I will use the term Specific Learning Disabilities (SLD) instead of SpLD, the reason for which will transpire in later sections of this article.
It is known that differences in the brain lead to SLD symptoms, and that these differences cannot be medically altered and will be persistent throughout the person's life time. Applying the medical model of management for a disability that is aimed mainly at cure, or the individual's adjustment and behaviour change, may be insufficient. Special education techniques, for example, can help people with SLD improve their ability to read, write or perform mathematics. Many people with SLD can learn effectively and succeed at school, and can become accomplished in areas that require academic excellence.
The disabilities associated with SLD are a social construct, I argue, and so it is the collective responsibility of society at large to help people with SLD to fully integrate into society. Medical practitioners can go a long way to help achieve this goal.
Specific Learning Disabilities is a Disability
SLD is a general term that refers to a heterogeneous group of disorders manifested by significant difficulties in the acquisition and use of listening, speaking, reading, writing, reasoning or mathematical abilities.2 In the past, SLD was not recognised by the Government as a category of disability requiring rehabilitation services despite the Disability Discrimination Ordinance (DDO), enacted in 1995, clearly stating that disability, in relation to a person, "includes a disorder or malfunction that results in the person learning differently from a person without the disorder or malfunction".
The most prevalent type of SLD is dyslexia, which is a language-based learning disability. Students with Dyslexia have difficulty understanding, remembering and working with letter sounds (phonological awareness), in isolation and/or within words, sentences or paragraphs. Dyslexia not only affects reading, but also spelling, writing and listening.3 Clearly, children with SLD such as dyslexia, dysgraphia, mathematics disorder, or visual-spatial-perceptual impairment, etc are persons with disabilities as defined under the DDO.
From Denial to Recognition
When the Equal Opportunities Commission (EOC) was preparing the Code of Practice (CoP) on Education under the DDO in 2000, feedback was received from the then Education Department suggesting that SLD should not be regarded as a "disability" as such, requiring special treatment or accommodation from schools. There was contention that educational needs of every student, not just those with SLD, are different. Hence, the "learning difficulties" of students with SLD had already been catered for by the existing educational strategy of addressing "individual differences" adopted by schools. Despite the feedback, EOC used dyslexia (a form of SLD) in an example to illustrate disability discrimination in the CoP on Education issued under the DDO.
It is gratifying to note that after seven long years, the Government has finally decided to include SLD as a category of disability in the new RPP. The inclusion of SLD as a category of disability in the new RPP is a ground breaking development for people with these conditions. It is a necessary and an important first step in the right direction that has the effect of requiring relevant administrators to start thinking about formulating appropriate public policies and programmes to cater for the special needs of people with SLD, especially students with SLD.
The Social Model of Disability
Since the Government has now recognised SLD as a disability, let us take a look at what "disability" is.
Several models have characterised the history of disability: The religious model, the medical/genetic model, and more recently the social/human-rights model.4 These models or constructions of disability have had a powerful influence on setting the parameters for how people with impairments are treated by society.
According to the medical model the problem of disability is located within the individual, i.e. a person is disabled due to their individual impairments and therefore requires medical interventions to provide the person with the skills to adapt to society.
The social model of disability, however, makes an important distinction between the terms impairment and disability. The social model sees the issue mainly as a socially created problem, and basically as a matter of the full integration of individuals into society. Disability is not an attribute of an individual, but rather a complex collection of conditions, many of which are created by the social environment. Hence the management of the problem requires social action, and it is the collective responsibility of society at large to make the environmental modifications necessary for the full participation of people with disabilities in all areas of social life.5
The distinction between impairment, disability and handicap under the definitions adopted by the World Health Organization is re-produced below for easy reference of readers:
(1) Impairment - any loss or abnormality of psychological, physiological, or anatomical structure or function.
(2) Disability - any restriction or lack (resulting from an impairment) of ability to perform an activity in the manner or within the range considered normal for a human being.
(3) Handicap - a disadvantage for a given individual, resulting from an impairment or disability, that limits or prevents the fulfillment of a role that is normal, depending on age, sex, social and cultural factors, for that individual.
Rights of Students with Specific Learning Disabilities in Hong Kong
Under Section 24(2) of the DDO, it is unlawful for an educational establishment to discriminate (either directly or indirectly) against a student with a disability by denying that student's access, or limiting that student's access, to any benefit, service or facility provided by the educational establishment; by expelling that student; or by subjecting that student to any detriment. Educational establishments also have the obligation to provide reasonable accommodation to a student with a disability except where there can be shown to be unjustifiable hardship.
Reasonable accommodations are measures or actions taken in order to provide equal opportunities for a student with disability, such as the provision of aids, facilities or services to meet that student's individual needs. A detailed assessment may be required in order to determine what accommodations are necessary and each case needs to be considered with regard to its own circumstances. Educational establishments have the obligation to make reasonable accommodations in their existing programmes, services, facilities and benefits in order to meet the needs of their students with disabilities.
The DDO is also binding on the Government. Section 36(1) of the DDO specifies that it is unlawful for the Government to discriminate against a person with a disability in the performance of its functions or the exercise of its powers. Thus, the Government has an obligation to develop appropriate policies and deploy reasonable resources to support equal opportunities for persons with disabilities in all aspects of education.6
Relevant International Treaties
Apart from needing to fulfill legal obligation of non-discrimination, the Government is further bound by various international treaties, notably the UN Convention on the Rights of the Child (CRC) and the newly adopted UN Convention on the Rights of Persons with Disabilities (CRPD), to provide appropriate support services to people with disabilities.
Article 23(3) of the CRC stipulates assistance extended to a disabled child by States Parties "shall be designed to ensure that the disabled child has effective access to and receives education, training, health care services, rehabilitation services, preparation for employment and recreation opportunities in a manner conducive to the child's achieving the fullest possible social integration and individual development."
Article 24(2) of the CRPD, on the other hand, stipulates " States parties shall ensure that:
(1) persons with disabilities (PWD) are not excluded from the general education system on the basis of disability, and that children with disabilities are not exclude from free and compulsory primary education, or from secondary education, on the basis of disability;
(2) PWD can access an inclusive, quality and free primary education and secondary education on an equal basis with others in the communities in which they live;
(3) reasonable accommodation of the individual's requirements is provided;
(4) PWD receive the support required, within the general education system, to facilitate their effective education; and
(5) effective individualised support measures are provided in environments that maximise academic and social development, consistent with the goal of full inclusion."
To summarise, the key obligations created by the DDO and relevant international treaties in relation to persons with SLD include elimination of disability discrimination, provision of reasonable accommodations, provision of individualised support services in consultation with the user with disability, involvement of stakeholders in the formulation of relevant public policies and programmes, implementation of effective public education strategy to promote social integration, and allocation of adequate resources to cater for the special needs of people with disabilities.
Key Challenges and Existing Responses
In the following paragraphs, key challenges and existing situation on the implementation of integrated education for students with SLD in Hong Kong are presented for readers' information. With this overall picture in mind, you can act as a resource person for patients with SLD or their parents, and will be better prepared to answer questions that are commonly asked. These include:
The vast majority of students with SLD will begin their educational experience in a regular school. Early identification of students with SLD is therefore crucial to the provision of timely intervention and support in both academic and affective domains.
Currently, Child Assessment Service of the Department of Health (DH) provides multidisciplinary services for assessing children up to age 12 with developmental problems. Student Health Service (SHS) of DH, on the other hand, provides free annual health assessment in Student Health Service Centre for all primary and secondary school students joining the Service. For suspected cases of SLD, further psychological health and psychological assessments will be conducted in SHS's Special Assessment Centres. The Education Bureau (EDB) has also developed an Observation Checklist for Teachers (OCT) to help teachers identify students with SLD at the end of the first semester of Primary One. This has been in use since September 2004. There is, however, criticism that the Government has transferred the responsibility of identifying SLD students to teachers of primary schools, while not providing sufficient professional development for these teachers on identification of students with SLD. On the other hand, parents are also frustrated with the long waiting time for assessment of SLD by educational psychologists.
School-based Supports and Modulation of Assessment
High quality specialised instruction at school is needed to ensure that students with SLD can learn effectively. Moreover, accommodations in assessment or alternative assessment should be considered so that the true potential and performance of these students can be measured. In this connection, the EDB has issued guidance to schools on assessment accommodations in internal examination, for students with special educational needs (SEN), including students with SLD. Starting from the 2006-07 school year, EDB has also assigned to each primary school a contact officer to advise on the provision of support and assistance to students with SEN. These contact officers serves as a resource person to help schools promote inclusive culture and to advise schools on support mechanisms and differentiated instruction for students with SEN. The Student Support Team of individual schools are also expected to discuss with educational psychologists, contact officers and parents concerned, on the appropriate assessment accommodation arrangements for individual students with SEN.
Special Arrangements in Public Examinations
Provision of reasonable accommodation in public examinations for students with SLD is essential for them to compete with their peers on a truly equal basis. Without accommodations such as extra time, supervised rest periods during examination, or special seating arrangement etc, their true potential and abilities may be concealed.
With effect from the 2005-06 school year, students with SEN at Secondary 4 and Secondary 6 levels, including students with SLD, can apply at the commencement of the school year for special arrangements in their Hong Kong Certificate of Education Examination (Secondary 5) and Hong Kong Advanced Level Examination (Secondary 7) respectively. These special arrangements may include extra time, enlarged question and answer sheets, supervised rest periods, exemptions and physical accommodations such as special centres or seating arrangements. The Hong Kong Examination and Assessment Authority (HKEAA) will consider their applications, and provide responses in February of the school year.
Parents are the best advocate for their children, and parent education is the key in ensuring that children with SLD have the best possible learning conditions. Parents' awareness on SLD and on the corresponding support services available from EDB and at schools should be enhanced, so that they can make informed decisions. This is the same as for parents of children without disabilities, when they need to make school choices or seek support.
To facilitate parents of children with SEN, including those with SLD, in making school choices, EDB conducts regional briefing sessions for parents of pre-P1 children on a regular basis. EDB has also revised the layout and explanatory notes of School Profiles, and encouraged schools to indicate their experience and measures in SEN support for parents' reference. In addition, EBD recently issued a circular memorandum, reminding schools to obtain parental consent for transferring students' SEN data between schools when students change schools. This will facilitate new schools to provide timely and appropriate support to the students. Information leaflets have also been produced to help parents understand their children's special educational needs and methods of remediation.
Role of Medical Practitioners
Medical practitioners, particularly paediatricians and family doctors, can go a long way to help people with SLD enjoy full participation in society. Promotion of the family-doctor concept in the community with a view to enhancing primary health care is a stated policy of the Food and Health Bureau. On the other hand, awareness of SLD among parents and teachers will certainly be increased when more promotional activities roll out after the inclusion of SLD in the new RPP. It is anticipated that more and more children, and even adults who previously have not been identified as persons with SLD, will present themselves for assessment or diagnosis when they are in doubt.
As a medical practitioner, you should keep yourself abreast of various barriers that people with SLD are facing, the solutions or accommodations to these barriers, and the existing channels through which they can get assistance. Be prepared to help in the following areas:
The above is by no means an exhaustive list of areas whereby a medical practitioner may help in advancing the basic human rights of people with SLD. There is an old saying reminding us of the need to "treat the person, not the disease". This is not only a challenge but also a worthy mission for medical practitioners.
1. Labour and Welfare Bureau. 2007 Rehabilitation Programme Plan. HKSAR, 2007.
2. Taymans JM, West LL, Sullivan M, Scheiber B. Unlocking Potential: College and Other Choices for People with LD and AD/HD. Bethesda, MD: Woodbine House, 2000.
3. Tse AYK. The Role of Occupational Therapists for Students with Specific Learning Disabilities in Vocational Education. Hong Kong Occupational Therapy Association, October 2005.
4. Clapton J, Fitzgerald J. The History of Disability: A History of 'Otherness'. New Renaissance magazine: Vol 7, No 1, 1997. http://www.ru.org/artother.html
5. World Health Organization. International Classification of Functioning, Disability and Health (ICF) Introduction. ICF Home Page, 2001. http://www.who.int/classifications/icf/site/intros/ICF-Eng-Intro.pdf
6. Equal Opportunities Commission. Disability Discrimination Ordinance Code of Practice on Education. HKSAR, July 2001.