A taxometric investigation of developmental dyslexia subtypes

Towards a dynamic, comprehensive conceptualization of dyslexia

Here we build from the central strength of the existing definition of dyslexia-its emphasis on neurobiological origins-and proffer a set of seven core principles for a new, more comprehensive conceptualization of dyslexia. These principles derive from two major research directions: (1) the still evolving history of attempts to explain dyslexia, including in varied writing systems; and (2) the study of the reading brain circuit, its development, and its genetic and environmental influences. What emerges from connecting these two directions is a dynamic conceptualization of dyslexia that incorporates the extensive research on the heterogeneity of dyslexia and the interdependent contributions of multiple biological and socio-cultural risk and preventive factors. A new definition of dyslexia, therefore, needs to transcend both past unitary characterizations and past assumptions based largely on the English orthography. Such a conceptualization references the ways that different languages interact with the reading brain circuit to produce different sources of reading failure. Similarly, the characteristics and consequences of dyslexia that have been considered as secondary sequela (e.g., reduced reading comprehension, social-emotional issues) should be part of a more comprehensive narrative. Of critical importance, any definition of dyslexia should clarify persisting misconceptions that associate dyslexia with a lack of intelligence, potential to learn, or talents. Thus, the overall purpose of such a definition should serve as an instrument of knowledge and an enduring reason for pursuing growth in reading for the individual, the educator, and the public.

Children with developmental dyslexia show elevated parasympathetic nervous system activity at rest and greater cardiac deceleration during an empathy task

Reading difficulties are the hallmark feature of dyslexia, but less is known about other areas of functioning. Previously, we found children with dyslexia exhibited heightened emotional reactivity, which correlated with better social skills. Whether emotional differences in dyslexia extend to the parasympathetic nervous system-an autonomic branch critical for attention, social engagement, and empathy-is unknown. Here, we measured autonomic nervous system activity in 24 children with dyslexia and 24 children without dyslexia, aged 7 - 12, at rest and during a film-based empathy task. At rest, children with dyslexia had higher respiratory sinus arrhythmia (RSA) than those without dyslexia. Cardiac deceleration during the empathy task was greater in dyslexia and correlated with higher resting RSA across the sample. Children with dyslexia produced more facial expressions of concentration during film-viewing, suggesting greater engagement. These results suggest elevated resting parasympathetic activity and accentuated autonomic and behavioral responding to others' emotions in dyslexia.

Are Different Types of Learning Disorder Associated With Distinct Cognitive Functioning Profiles?

Introduction: DSM-5 presented a revised conceptualization of specific learning disorders (LD). Contrary to former versions, the various types of LD-i.e., mathematics disorder, reading disorder, and writing disorder-are not treated as distinct diagnostic entities but are integrated into one single LD category. In support of this new classification, it has been argued that the various types of LD overlap to a great extent in their cognitive functioning profiles and therefore do not exhibit a distinct set of cognitive causes. In contrast, ICD-11 still adheres to the idea of discrete categories and thus follows the specificity hypothesis of LD. Using latent profile analysis (LPA), we therefore tested the specificity of cognitive strengths and weaknesses in children with different types of LD. Secondly, we aimed at examining the extent to which observed LD characteristics (type and severity of LD as well as IQ-achievement discrepancy) were consistent with the membership of a given latent profile. Method: 302 German third-graders (134 girls; IQ ≥ 85; M age = 111.05 months; SD = 5.76) with single or comorbid types of LD in the domains of mathematics, reading, and spelling completed a wide range of domain-specific and domain-general cognitive functioning measures. Results: Five qualitative distinct profiles of cognitive strengths and weaknesses were identified. Profile 1 (23% of the sample) showed Comprehensive Cognitive Deficits, performing low in all measures except for naming speed, language, and inhibition. Profile 2 (21%) included children with a Double Deficit in Phonological Awareness and Phonological Short-term Memory. Profile 3 (20%) was characterized by a Double Deficit of Phonological Awareness and Naming Speed. Profile 4 (19%) included children with a Single Deficit in Attention, and profile 5 (17%) consisted of children without any cognitive deficits. Moreover, type and severity of LD as well as IQ-achievement discrepancy discriminated between the profiles, which is in line with the specificity hypothesis of LD. Discussion: Overall, the finding of specific associations between the LD types and the identified cognitive profiles supports the ICD-11 classification of LD. Yet, those inferences may not be valid for an individual child but need to be examined through comprehensive diagnostic.

Action video game training improves text reading accuracy, rate and comprehension in children with dyslexia: a randomized controlled trial

Dynamic visual attention training using Action Video Games (AVGs) is a promising intervention for dyslexia. This study investigated the efficacy of 5 h (10 × 30 min) of AVG training in dyslexic children (aged 8–13) using ‘Fruit Ninja’, while exploring whether increasing attentional and eye movement demands enhanced AVG effectiveness. Regular (AVG-R; n = 22) and enhanced AVG training (AVG+; n = 23) were compared to a treatment-as-usual comparison group (n = 19) on reading, rapid naming, eye movements and visuo-temporal processing. Playing ‘Fruit Ninja’ for only 5 h significantly improved reading accuracy, rate, comprehension and rapid naming of both AVG groups, compared to the comparison group, though increasing attentional demands did not enhance AVG efficacy. Participants whose low contrast magnocellular-temporal processing improved most following training also showed significantly greater improvement in reading accuracy. The findings demonstrate a clear role for visual attention in reading and highlight the clinical applicability of AVGs as a fun, motivational and engaging intervention for dyslexia.

Developmental dyslexia and creativity: A meta-analysis

Despite difficulties in reading and writing, some research suggests that dyslexia may be related to higher levels of creativity. However, this pattern is not consistently observed. The current research sought to ascertain whether individuals with clinically diagnosed dyslexia exhibit higher creativity than controls through a meta-analysis. Fourteen studies that assessed the creativity of 397 individuals with clinically diagnosed dyslexia and 453 controls were reviewed. Random-effects meta-analysis revealed an overall non-significant difference in creativity scores between those with dyslexia and controls. Additionally, method factors such as the type of creativity task and whether intelligence was controlled for, as well as sample-related factors such as gender, did not explain differences in the dyslexia-creativity relationship. Nonetheless, individuals with dyslexia significantly outperformed controls in creativity scores in adult samples, but not in younger child/adolescent samples. Overall, the current findings provide limited support for the idea that individuals with dyslexia are more creative, and that past evidence of this relationship may be limited to adult samples.

Enhanced visceromotor emotional reactivity in dyslexia and its relation to salience network connectivity

Dyslexia is a neurodevelopmental disorder mainly defined by reading difficulties. During reading, individuals with dyslexia exhibit hypoactivity in left-lateralized language systems. Lower activity in one brain circuit can be accompanied by greater activity in another, and, here, we examined whether right-hemisphere-based emotional reactivity may be elevated in dyslexia. We measured emotional reactivity (i.e., facial behavior, physiological activity, and subjective experience) in 54 children ages 7-12 with (n = 32) and without (n = 22) dyslexia while they viewed emotion-inducing film clips. Participants also underwent task-free functional magnetic resonance imaging. Parents of children with dyslexia completed the Behavior Assessment System for Children, which assesses real-world behavior. During film viewing, children with dyslexia exhibited significantly greater reactivity in emotional facial behavior, skin conductance level, and respiration rate than those without dyslexia. Across the sample, greater emotional facial behavior correlated with stronger connectivity between right ventral anterior insula and right pregenual anterior cingulate cortex (pFWE<.05), key salience network hubs. In children with dyslexia, greater emotional facial behavior related to better real-world social skills and higher anxiety and depression. Our findings suggest there is heightened visceromotor emotional reactivity in dyslexia, which may lead to interpersonal strengths as well as affective vulnerabilities.

Flicker fusion thresholds as a clinical identifier of a magnocellular-deficit dyslexic subgroup

The magnocellular-dorsal system is well isolated by high temporal frequency. However, temporal processing thresholds have seldom been explored in developmental dyslexia nor its subtypes. Hence, performances on two, four-alternative forced-choice achromatic flicker fusion threshold tasks modulated at low (5%) and high (75%) temporal contrast were compared in dyslexic and neurotypical children individually matched for age and intelligence (8–12 years, n = 54 per group). As expected, the higher modulation resulted in higher flicker fusion thresholds in both groups. Compared to neurotypicals, the dyslexic group displayed significantly lower ability to detect flicker at high temporal frequencies, both at low and high temporal contrast. Yet, discriminant analysis did not adequately distinguish the dyslexics from neurotypicals, on the basis of flicker thresholds alone. Rather, two distinct dyslexic subgroups were identified by cluster analysis – one characterised by significantly lower temporal frequency thresholds than neurotypicals (referred to as ‘Magnocellular-Deficit’ dyslexics; 53.7%), while the other group (‘Magnocellular-Typical’ dyslexics; 46.3%) had comparable thresholds to neurotypicals. The two dyslexic subgroups were not differentially associated with phonological or naming speed subtypes and showed comparable mean reading rate impairments. However, correlations between low modulation flicker fusion threshold and reading rate for the two subgroups were significantly different (p = .0009). Flicker fusion threshold performances also showed strong classification accuracy (79.3%) in dissociating the Magnocellular-Deficit dyslexics and neurotypicals. We propose that temporal visual processing impairments characterize a previously unidentified subgroup of dyslexia and suggest that measurement of flicker fusion thresholds could be used clinically to assist early diagnosis and appropriate treatment recommendations for dyslexia.

Dimensions over categories: a meta-analysis of taxometric research

Taxometric procedures have been used extensively to investigate whether individual differences in personality and psychopathology are latently dimensional or categorical ('taxonic'). We report the first meta-analysis of taxometric research, examining 317 findings drawn from 183 articles that employed an index of the comparative fit of observed data to dimensional and taxonic data simulations. Findings supporting dimensional models outnumbered those supporting taxonic models five to one. There were systematic differences among 17 construct domains in support for the two models, but psychopathology was no more likely to generate taxonic findings than normal variation (i.e. individual differences in personality, response styles, gender, and sexuality). No content domain showed aggregate support for the taxonic model. Six variables - alcohol use disorder, intermittent explosive disorder, problem gambling, autism, suicide risk, and pedophilia - emerged as the most plausible taxon candidates based on a preponderance of independently replicated findings. We also compared the 317 meta-analyzed findings to 185 additional taxometric findings from 96 articles that did not employ the comparative fit index. Studies that used the index were 4.88 times more likely to generate dimensional findings than those that did not after controlling for construct domain, implying that many taxonic findings obtained before the popularization of simulation-based techniques are spurious. The meta-analytic findings support the conclusion that the great majority of psychological differences between people are latently continuous, and that psychopathology is no exception.

Global and Local Visual Processing in Rate/Accuracy Subtypes of Dyslexia

Words are processed in both a global and local manner. Studies on global versus local processing styles in individuals with and without dyslexia are inconclusive. In the present study, we investigated whether distinct patterns of global/local visual processing were associated with more precisely defined dyslexia profiles. Previous studies on dyslexia provide evidence of accuracy- and rate-based subtypes, with impairment in one dimension alongside normal performance in the other. In the current study, three groups of adult readers: rate disability, accuracy disability, typical development, were presented with nonlinguistic global /local congruency task. The results revealed that the rate disability group had deficiencies performing the global task while the accuracy disability group had deficiencies in the local task. These results are discussed in the context of global/local word processing and in relation to dyslexia. Specifically, they suggest that different patterns of global/local processing are observed between different types of dyslexics, and imply that practitioners should modify their treatment based on the specific deficiency.

Latent profile analysis of students' reading development and the relation of cognitive variables to reading profiles

Previous studies have showed that early problems with word decoding can lead to poor performance in text reading and comprehension and suggest that poor readers often struggle with reading deficits throughout their school years. Therefore, early detection of those children who are at risk for slow reading development and/or who belong to the lowest reading profiles is essential in order to organize proper support. The present study explores the heterogeneity and prevalence of latent reading profiles among 769 Finnish- and German-reading students during their first and second school years in three countries (Finland, Germany, and Italy) using latent profile analysis. The results identified three latent profiles among Finnish readers, one of which (sentence-level reading) was identified as developing slowly. Among German-reading students, four latent profiles were discovered, two of which were identified as developing slowly. The results of ordinal logistic regression modeling show that rapid automatic naming (RAN) was significantly related to poorer reading profiles among Finnish- and German-reading students, and that the poorer results in letter-sound connection testing among the German-reading group was also significantly related to poorer reading profiles. Although the educational systems have some differences between Germany and German-speaking areas of Italy, no significant country effect was detected. In addition, a child's age and spoken language did not significantly affect the student's reading profile.

Eye Movements During RAN as an Operationalization of the RAN-Reading "Microcosm"

Rapid Automatized Naming (RAN) is a strong predictor of reading aloud, though there is little agreement on what underpins RAN or how it relates to reading. Some theorize phonological skills, while others suggest that RAN reflects the “microcosm” of cognitive and attentional processes also required for reading, with more recent research using eye movements in an attempt to study this relationship. In the current study, we aimed to extend previous investigations to identify whether the temporal patterns of eye movements predict RAN and can, therefore, be established as a method to study the cognitive processes underlying RAN that could then be utilized to elucidate the relationship of RAN to reading. A Gazepoint eye tracker was used to record the eye movements of 93 learner readers aged 5–8 years (M age = 7.00) while performing a custom computerized alphabetic RAN task. Text reading accuracy, comprehension and rate; nonverbal intelligence; and phonological awareness abilities were also assessed. Regression analyses showed that, independently of phonological awareness, eye movements [Fixation Count (FC) and Fixation Duration (FD)] measured during RAN tasks were highly reflective of children’s rapid naming performance (92.8%). Both mean FC and mean FD during RAN tasks also predicted text reading accuracy (36.3%), comprehension (31.6%), and rate (36.2%) scores, and in predicting these text reading skills there was a high level of shared variance with RAN performance. In a sub-sample of participants, longer average FDs and counts independently discriminated children with reading difficulties (n = 18; aged 7–9) from neurotypical children matched for age (n = 18), but not from younger neurotypical children matched for reading level (n = 18; aged 5–6). Together, these results suggest that the analysis of eye movements recorded during RAN allows for the operationalization of many of the spatially and temporally-bound cognitive and attentional processes that underpin the RAN, and a step towards elucidating its relationship to reading.

Effect of READ1 on latent profiles of reading disorder and comorbid attention and language impairment subtypes

Recent studies of co-occurring reading disorder (RD) and attention deficit/hyperactivity disorder (ADHD), and co-occurring RD and language impairment (LI), support a core disability plus co-occurrence model focused on language and attention. Genetic factors have been associated with poor reading performance. However, little is known about whether different genetic variants independently contribute to RD co-occurrence subtypes. We aimed to identify subgroups of struggling readers using a latent profile analysis (LPA) in a sample of 1,432 Hispanic American and African American youth. RD classes were then tested for association with variants of READ1, a regulatory element within the candidate RD risk gene, DCDC2. Six groups were identified in the LPA using RD designation as a known-class variable. The three RD classes identified groups of subjects with neurocognitive profiles representing RD+ADHD, specific phonological deficit RD, and RD+LI. Genetic associations across RD subtypes were investigated against functional groupings of READ1. The RU1-1 group of READ1 alleles was associated with RD cases that were marked by deficits in both processing speed and attention (RD+ADHD). The DCDC2 microdeletion that encompasses READ1 was associated with RD cases showing a phonological deficit RD profile. These findings provide evidence for differential genetic contribution to RD subtypes, and that previously implicated genetic variants for RD may share an underlying genetic architecture across population groups for reading disorder.

Investigating the Influences of Language Delay and/or Familial Risk for Dyslexia on Brain Structure in 5-Year-Olds

Early language delay has often been associated with atypical language/literacy development. Neuroimaging studies further indicate functional disruptions during language and print processing in school-age children with a retrospective report of early language delay. Behavioral data of 114 5-year-olds with a retrospective report of early language delay in infancy (N = 34) and those without (N = 80) and with a familial risk for dyslexia and those without are presented. Behaviorally, children with a retrospective report of early language delay exhibited reduced performance in language/reading-related measures. A voxel-based morphometry analysis in a subset (N = 46) demonstrated an association between reduced gray matter volume and early language delay in left-hemispheric middle temporal, occipital, and frontal regions. Alterations in middle temporal cortex in children with a retrospective report of early language delay were observed regardless of familial risk for dyslexia. Additionally, while children with isolated familial risk for dyslexia showed gray matter reductions in temporoparietal and occipitotemporal regions, these effects were most profound in children with both risk factors. An interaction effect of early language delay and familial risk was revealed in temporoparietal, occipital, and frontal cortex. Our findings support a cumulative effect of early behavioral and genetic risk factors on brain development and may ultimately inform diagnosis/treatment.

Longitudinal stability of pre-reading skill profiles of kindergarten children: implications for early screening and theories of reading

Research suggests that early identification of developmental dyslexia is important for mitigating the negative effects of dyslexia, including reduced educational attainment and increased socioemotional difficulties. The strongest pre-literacy predictors of dyslexia are rapid automatized naming (RAN), phonological awareness (PA), letter knowledge, and verbal short-term memory. The relationship among these constructs has been debated, and several theories have emerged to explain the unique role of each in reading ability/disability. Furthermore, the stability of identification of risk based on these measures varies widely across studies, due in part to the different cut-offs employed to designate risk. We applied a latent profile analysis technique with a diverse sample of 1215 kindergarten and pre-kindergarten students from 20 schools, to investigate whether PA, RAN, letter knowledge, and verbal short-term memory measures differentiated between homogenous profiles of performance on these measures. Six profiles of performance emerged from the data: average performers, below average performers, high performers, PA risk, RAN risk, and double-deficit risk (both PA and RAN). A latent class regression model was employed to investigate the longitudinal stability of these groups in a representative subset of children (n = 95) nearly two years later, at the end of 1st grade. Profile membership in the spring semester of pre-kindergarten or fall semester of kindergarten was significantly predictive of later reading performance, with the specific patterns of performance on the different constructs remaining stable across the years. There was a higher frequency of PA and RAN deficits in children from lower socioeconomic status (SES) backgrounds. There was no evidence for the IQ-achievement discrepancy criterion traditionally used to diagnose dyslexia. Our results support the feasibility of early identification of dyslexia risk and point to the heterogeneity of risk profiles. These findings carry important implications for improving outcomes for children with dyslexia, based on more targeted interventions.

What Reading Disability? Evidence for Multiple Latent Profiles of Struggling Readers in a Large Russian Sibpair Sample With at Least One Sibling at Risk for Reading Difficulties

In this study, we performed a latent profile analysis of reading and related skills in a large ( n = 733) sibpair sample of Russian readers at risk for reading difficulties. The analysis suggested the presence of seven latent profiles, of which two were characterized by relatively high performance on measures of spelling and reading comprehension and the remaining five included severely as well as moderately affected readers with deficits in the domains of phonological, orthographic, and morphological processing. The results suggest that the development and manifestation of reading difficulties in Russian is mappable on a complex pattern of interactions between different types and severities of processing deficits. The results point to the psychological reality of multiple different suboptimal patterns of deficits in reading and reading-related skills and support the multifactorial view of the disorder, with intriguing implications for future neurobiological studies.

Examining the relationship between home literacy environment and neural correlates of phonological processing in beginning readers with and without a familial risk for dyslexia: an fMRI study

Developmental dyslexia is a language-based learning disability characterized by persistent difficulty in learning to read. While an understanding of genetic contributions is emerging, the ways the environment affects brain functioning in children with developmental dyslexia are poorly understood. A relationship between the home literacy environment (HLE) and neural correlates of reading has been identified in typically developing children, yet it remains unclear whether similar effects are observable in children with a genetic predisposition for dyslexia. Understanding environmental contributions is important given that we do not understand why some genetically at-risk children do not develop dyslexia. Here, we investigate for the first time the relationship between HLE and the neural correlates of phonological processing in beginning readers with (FHD+, n = 29) and without (FHD-, n = 21) a family history of developmental dyslexia. We further controlled for socioeconomic status to isolate the neurobiological mechanism by which HLE affects reading development. Group differences revealed stronger correlation of HLE with brain activation in the left inferior/middle frontal and right fusiform gyri in FHD- compared to FHD+ children, suggesting greater impact of HLE on manipulation of phonological codes and recruitment of orthographic representations in typically developing children. In contrast, activation in the right precentral gyrus showed a significantly stronger correlation with HLE in FHD+ compared to FHD- children, suggesting emerging compensatory networks in genetically at-risk children. Overall, our results suggest that genetic predisposition for dyslexia alters contributions of HLE to early reading skills before formal reading instruction, which has important implications for educational practice and intervention models.

Phonological awareness and sinusoidal amplitude modulation in phonological dislexia

OBJECTIVE

Dyslexia is the difficulty of children in learning to read and write as results of neurological deficiencies. The objective was to test the Phonological awareness (PA) and Sinusoidal amplitude modulation (SAM) threshold in children with Phonological dyslexia (PD).

METHODS

We performed a case-control, analytic, cross sectional study. We studied 14 children with PD and 14 control children from 7 to 11 years of age, by means of PA measurement and by SAM test. The mean age of dyslexic children was 8.39 years and in the control group was 8.15.

RESULTS

Children with PD exhibited inadequate skills in PA, and SAM. We found significant correlations between PA and SAM at 4 Hertz frequency, and calculated regression equations that predicts between one-fourth and one-third of variance of measurements.

CONCLUSION

Alterations in PA and SAM found can help to explain basis of deficient language processing exhibited by children with PD.

Examination of the double-deficit hypothesis with adolescents and young adults with dyslexia

The double-deficit hypothesis (DDH) of the developmental dyslexias (Wolf and Bowers, Journal of Educational Psychology, 91, 415-438, 1999) was investigated with 149 adolescents and young adults (age range = 16 to 24 years) with dyslexia. Confirmatory factor analysis indicated that a two-factor model with separate naming speed (NS) and phonological awareness (PA) constructs was superior to a one-factor model, supporting the assumption within the DDH that NS is a source of reading dysfunction separable from PA. Hierarchical multiple regression analyses resulted in findings that were only partially supportive of the DDH. NS was predictive of word reading, spelling, and reading fluency beyond PA and verbal intellectual ability, but not pseudoword reading and timed and untimed reading comprehension. Examination of DDH subtypes did not support the core assumption of the DDH that the double-deficit subtype would have more impaired reading skills than both of the single-deficit subtypes. The NS deficit subtype was found to be more prevalent than the double-deficit and PA deficit subtypes within the subgroup of dyslexics with impairment in reading fluency. Overall results provided mixed support for the DDH and pointed to the need for the inclusion of additional abilities within theories of the underlying mechanisms disrupted in dyslexia.

Predictors of reading in Urdu: does deep orthography have an impact?

The aim of this study was to establish the extent to which rapid automatized naming (RAN) and non-word repetition (NWR) tasks predict reading fluency and reading accuracy in Urdu. One hundred sixty (8-9 years) children attending two types of schools (Urdu and English medium schools) were distributed into two groups, a control and a reading disability group on the basis of teacher's report. The results confirmed the role of RAN in predicting reading fluency in both groups. The role of NWR as a predictor of accuracy was also confirmed, although the strength of the relationship was modulated by RAN in the reading disability group. There are no tests available to identify children with reading problems in Urdu. Our study supports the validity of NWR and RAN tasks for the purposes of screening for reading deficits. The performance results also confirm the original grouping based on teacher reports. The study further highlights the importance of medium of instruction and increased oral language input in learning to read.

Altered neuronal response during rapid auditory processing and its relation to phonological processing in prereading children at familial risk for dyslexia

Developmental dyslexia (DD) is a learning disability affecting 5-17% of children. Although researchers agree that DD is characterized by deficient phonological processing (PP), its cause is debated. It has been suggested that altered rapid auditory processing (RAP) may lead to deficient PP in DD and studies have shown deficient RAP in individuals with DD. Functional neuroimaging (fMRI) studies have implicated hypoactivations in left prefrontal brain regions during RAP in individuals with DD. When and how these neuronal alterations evolve remains unknown. In this article, we investigate functional networks during RAP in 28 children with (n = 14) and without (n = 14) a familial risk for DD before reading onset (mean: 5.6 years). Results reveal functional alterations in left-hemispheric prefrontal regions during RAP in prereading children at risk for DD, similar to findings in individuals with DD. Furthermore, activation during RAP in left prefrontal regions positively correlates with prereading measures of PP and with neuronal activation during PP in posterior dorsal and ventral brain areas. Our results suggest that neuronal differences during RAP predate reading instruction and thus are not due to experience-dependent brain changes resulting from DD itself and that there is a functional relationship between neuronal networks for RAP and PP within the prereading brain.

Rethinking ADHD and LD in DSM-5: proposed changes in diagnostic criteria

The Diagnostic and Statistical Manual of Mental Disorders (DSM) is currently undergoing revision that will lead to a fifth edition (DSM-5) in 2013. This article first provides a brief synopsis of the DSM-5 administrative structure, procedures, and guiding principles to enhance understanding of how changes are made in the DSM. The next two sections (on attention-deficit/hyperactivity disorder and learning disorders, respectively) highlight the major concerns and controversies surrounding the DSM-IV diagnostic criteria for these two disorders and provide a rationale for the proposed changes to the criteria, along with a commentary on the empirical evidence on which the proposed changes were based.