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Learning disorders: How pediatricians can help
Learning disabilities can negatively affect the child, family, school, and, ultimately, society. Approximately 10% of US children have a learning disability.1 Unfortunately, learning disabilities are often unaddressed, under-addressed, or incorrectly addressed by family and schools.
Pediatricians are well positioned to address these concerns, refer for screenings and diagnoses, and provide additional support. This requires knowledge and skills to identify the risk factors for learning disabilities, recognize the early warning signs, and apply the appropriate diagnostic tools. Additionally, primary care pediatricians can support families with referrals to appropriate healthcare specialists and by communicating with patients’ schools.
LEARNING DISABILITIES DEFINED
There is no universal consensus regarding what constitutes a learning disability. The American Pediatrics Association defines specific learning disorder as reading, written expression, or mathematics skills that are substantially lower than expected for the individual’s age, measured intelligence, and age-appropriate education level or when achievement falls below a set standard.2
The Individuals with Disabilities Education Act (IDEA),3 which governs considerations schools must make for learning-disabled students, more broadly defines specific learning disability as impairment in one or more of the following: math, understanding or using written or spoken language, information processing, memory, and reading. Specific reading impairments include dyslexia, orthographic impairment (inability to memorize words), and hyperlexia disorder (comprehension difficulties). The IDEA also includes conditions such as perceptual disabilities, brain injury, minimal brain dysfunction, and developmental aphasia as learning disabilities.
EPIDEMIOLOGY
Approximately 10% of children in the United States have a learning disability. Of those affected, 40.7% have a learning disability in reading, language, math, information processing, or memory. Speech or language impairments affect 18.5%, of which dyslexia is the most common disability, affecting up to 80%. Mental retardation affects 7.4%, and 6.4% have serious emotional disturbances that prevent learning. In addition, up to 35% of those with a learning disorder have comorbid attention deficit hyperactivity disorder (ADHD) or other mental health difficulties including depression, anxiety, bipolar disorder, and obsessive compulsive disorder. Learning disabilities are twice as common in children with chronic health conditions.1,4,5
LEARNING DISABILITY ASSESSMENT
Medical conditions
The medical evaluation for suspected learning disability must be tailored to rule out obvious underlying or associated medical issues. Fetal alcohol syndrome, dysmorphisms, other syndromes, and apparent genetic causes should be ruled out.
Vision and hearing screens should be ordered and patients should be assessed for other potential sensory impairments that may resemble features of a learning disability. Medications such as anticonvulsants may have side effects that can cause learning difficulties and in older children, substance abuse must be ruled out.
Risk factors
A medical history should identify risk factors for learning disabilities. These include prematurity, low birth weight, early-life malnutrition, poverty and under-stimulating environments, head injury, epilepsy, and chronic health conditions. A family history of learning disabilities, including dyslexia or other learning disabilities, attention deficit, memory difficulty, and dropping out of school, are also risk factors.6
Early warning signs
Early warning signs of learning disability are listed in Table 1. Speech delay is particularly important to assess and parents should be asked about the child’s history of acquiring language. Children with problems discriminating sounds may present with difficulty in articulation.
Asking parents whether the child has trouble rhyming words, learning song lyrics, or carrying a tune is often helpful. For example, a child may be able to recite the words to “Happy Birthday to You” but cannot sing it. These questions provide information about ability to memorize words, follow directions, recite words back, and can indicate possible speech or hearing difficulties.
Written language ability can be assessed with pseudoword decoding or deciphering nonsense words based on phonemic awareness.
Although difficulty following directions can be an early warning sign, many children have problems in this area without a specific learning disability, especially if the direction is not in accordance with the level of neurological development (ie, complex instructions given to a younger child).
Fine motor skill impairment can be observed when children cannot easily hold utensils, button or buckle clothing, or manipulate small objects such as pencils and crayons. However, the ability to manipulate small objects should not rule out learning disability in institutionalized children or those from larger families, where small motor skills and independent dressing develop earlier. Other warning signs may be better indicators in these children.
Impaired visual-spatial processing may be manifested in a younger child as difficulty matching shapes and in an older child or adolescent as inability to copy information from a smart-board or whiteboard onto paper. Learning disabilities also may present as difficulty with processing of visual and auditory information.
Executive function
Learning disabilities can affect working memory and processing speed, which are basic cognitive processes subservient to the higher-order executive functions. The prefrontal cortex does not start to fully develop until a child is 7 to 8 years old. Impairment in this area may present as difficulties with time management, organization, or losing things. Those with right hemisphere involvement may have nonverbal learning disabilities exhibited as difficulty understanding math and word problems, and difficulty with perceptual reasoning. For example, the child may be able to repeat information in a rote manner but not grasp the meaning of what is said. This is sometimes termed a “cocktail personality,” in which a child’s conversation becomes nonsensical.
Nonverbal learning disabilities also are often seen in those with fetal alcohol syndrome or other fetal alcohol spectrum disorders such as alcohol-related neurodevelopmental disorder.
Attention deficit hyperactivity disorder
Learning disorders appear to have an established association with ADHD. Children with ADHD are twice as likely to have dyslexia, and, conversely, children with dyslexia are twice as likely to have ADHD. It is therefore difficult to establish which condition is primary. Did the ADHD behavior precede the dyslexia and accentuate a reading difficulty? Perhaps the dyslexia was primary, which led to inattentiveness on account of the inability to decipher words.
For these reasons, psychological assessments should be performed in a timely fashion to delineate the cause. It is easier for the general pediatrician to screen for attention problems than for dyslexia. Validated tests that screen for reading disorders in 3- to- 5-year-old children are not a routine part of well-child care.
SCHOOL SUPPORT
The IDEA requires that public schools assess children to determine their needs and provide the necessary support to address those needs.5 The goal is to ensure that all children receive free and appropriate education.
Assessment types
School districts’ assessments vary, but they are required to evaluate all areas of suspected disability, including during all parts of a school day, and to be carried out in a nonrestrictive environment (ie, educated in the regular classroom the student would attend if not disabled). The objective is to determine whether a child is eligible for an individualized education plan (IEP).
Schools have two options for learning disability assessment. The most common is a psychoeducational evaluation that includes cognitive and achievement assessment. Time limits for completing these assessments vary by state.
The alternative is to provide a response to intervention (RTI) approach. According to the National Center on RTI, “schools identify students at risk for poor learning outcomes, monitor student progress, provide evidence-based interventions, and adjust the intensity and nature of those interventions depending on a student’s responsiveness, and identify students with learning disabilities or other disabilities.”7 With RTI, there are varying levels of intensity, which may result in undue delays in education as a result of the observation period prior to intervention.
Any assessment requires evaluation of speech, language, and mathematics by a qualified professional, but the school is not required to do psychological or educational assessment. The role of school systems is not to provide comprehensive mental health support for students.
Individualized education plans
If an assessment finds a learning disability currently covered by IDEA (Table 2) and the disability affects effective educational progress, the school must develop an IEP for the student.
An IEP is a written contract outlining specific goals and measurable outcomes. It may include school placement determination and specific services like occupational therapy, physical therapy, speech, and/or special education services. The outcomes of an IEP can vary widely from state to state.
504 plans
When an assessment finds a covered disability but the disability is determined not to be a cause of educational impairment in terms of the child’s functioning in the school, the child will not qualify for an IEP but may be eligible for a 504 plan. Typically, a 504 plan involves making appropriate accommodation such as classroom seating location, homework modifications, and testing modifications.
Disagreement
There are options when the family and school disagree on the assessment outcome or the extent of an IEP plan. It is usually beneficial for the family to accept the IEP so that something is in place for the child while attempts are made to resolve the issue. In some cases, the family may choose to pursue their state-specific appeals process or mediation and/or to proceed to litigation. They also have the right to pursue independent assessment of their child’s suspected learning disability; however, this is an out-of-pocket expense that may not be covered by health insurance. Furthermore, the school is not required to accept independent assessor results or recommendations.
There may be benefits from independent neuropsychological evaluations because most school districts do not have access to neuropsychologists. Neuropsychological evaluations can provide a detailed assessment of higher-level cognitive abilities, such as executive function, memory, visual-spatial processing, visual-motor processing, language function, effort, and attention.
THE PEDIATRICIAN’S ROLE
School communication
The pediatrician can play a key role in requesting the initial multifactorial learning disability assessment on behalf of the family. Cleveland Clinic has template letters available for both the parents and the pediatrician to send to the school that can be adapted (Figure 1). Both should state the suspected learning disability ing disabilities and problems and should be addressed to the school principal.
Pediatricians can also communicate with the teacher about classroom strategies before an IEP or 504 Plan is determined, in order to help set the context of what may be coming. Surprisingly, many teachers are unfamiliar with requirements made for learning-disabled students, such as the benefits of seating the child toward the front of a class.
Talk to the child
The pediatrician should emphasize to the child that everyone learns differently and in a way best suited to him or her. The child should know that everyone’s brain works differently, and every child should try to work hard at school because it is their job in life at that age. Children can relate to an analogy that the brain is like a computer, with some models being faster than others and analyzing data differently.
Parents can help children build on their natural strengths and talents despite the learning disability. Point out that some children are good at math, others at reading, and some mainly excel at sports or the arts. It may be helpful to provide real-life examples of people who are successful despite learning disability, such as a celebrity with dyslexia.
Talk to the parents/guardians
Parents/guardians need to know that learning disability is not the result of poor parenting. Moreover, emphasize that the child is not lazy or stupid and that the condition can be very exhausting and frustrating for the child. Their child will have good and bad days, much like they do at their own work. Patience, rather than force, should be stressed.
Encourage parents to find alternative ways to teach their child that make it easier for them to learn. Online education programs may serve as beneficial supplements for these children, and field trips can provide more hands-on learning. In addition, talk to parents about the need for additional, independent testing and be able to refer them to appropriate sources for such testing as well as to neuropsychological resources, when warranted.
CONCLUSION
As families increasingly turn to pediatricians to address learning disabilities and problems children are having at school, physicians need to understand the various diagnoses and be able to assist with proper assessments. While schools must provide modifications when a diagnosis is made, there is sometimes disagreement about what the specific learning disability is and its extent of involvement in the child’s education. Diagnosing and addressing learning disability early can lessen various behavioral problems, help prevent dropping out of school, and enhance life outcomes for the child.
- Altarac M, Saroha E. Lifetime prevalence of learning disability among US children. Pediatrics 2007; 119(suppl 1):S77–S83.
- American Psychiatric Association. Diagnostic and Statistical Manual of Mental Disorders. 5th ed. Arlington, VA: American Psychiatric Association; 2013.
- Building the Legacy: IDEA 2004. U.S. Department of Education website. http://idea.ed.gov/. Accessed July 6, 2015.
- Pastor PN, Reuben CA. Diagnosed attention deficit hyperactivity disorder and learning disability: United States, 2004–2006. Vital Health Stat 10 2008; 237:1–14. http://www.cdc.gov/nchs/data/series/sr_10/Sr10_237.pdf. Accessed July 6, 2015.
- U.S. Department of Education, Office of Special Education and Rehabilitative Services. 29th Annual Report to Congress on the Implementation of the Individuals with Disabilities Education Act, 2007, vol 1. Washington, DC; 2010. http://www2.ed.gov/about/reports/annual/osep/2007/parts-b-c/29th-vol-1.pdf. Accessed July 6, 2015.
- National Joint Committee on Learning Disabilities. Learning Disabilities and Young Children: Identification and Intervention (technical report). October 2007. http://www.asha.org/policy/TR2007-00307/. Accessed July 6, 2015.
- Response to intervention (RTI). Center for Parent Information and Resources website. http://www.parentcenterhub.org/repository/rti/. Updated August 2012. Accessed July 6, 2015.
Learning disabilities can negatively affect the child, family, school, and, ultimately, society. Approximately 10% of US children have a learning disability.1 Unfortunately, learning disabilities are often unaddressed, under-addressed, or incorrectly addressed by family and schools.
Pediatricians are well positioned to address these concerns, refer for screenings and diagnoses, and provide additional support. This requires knowledge and skills to identify the risk factors for learning disabilities, recognize the early warning signs, and apply the appropriate diagnostic tools. Additionally, primary care pediatricians can support families with referrals to appropriate healthcare specialists and by communicating with patients’ schools.
LEARNING DISABILITIES DEFINED
There is no universal consensus regarding what constitutes a learning disability. The American Pediatrics Association defines specific learning disorder as reading, written expression, or mathematics skills that are substantially lower than expected for the individual’s age, measured intelligence, and age-appropriate education level or when achievement falls below a set standard.2
The Individuals with Disabilities Education Act (IDEA),3 which governs considerations schools must make for learning-disabled students, more broadly defines specific learning disability as impairment in one or more of the following: math, understanding or using written or spoken language, information processing, memory, and reading. Specific reading impairments include dyslexia, orthographic impairment (inability to memorize words), and hyperlexia disorder (comprehension difficulties). The IDEA also includes conditions such as perceptual disabilities, brain injury, minimal brain dysfunction, and developmental aphasia as learning disabilities.
EPIDEMIOLOGY
Approximately 10% of children in the United States have a learning disability. Of those affected, 40.7% have a learning disability in reading, language, math, information processing, or memory. Speech or language impairments affect 18.5%, of which dyslexia is the most common disability, affecting up to 80%. Mental retardation affects 7.4%, and 6.4% have serious emotional disturbances that prevent learning. In addition, up to 35% of those with a learning disorder have comorbid attention deficit hyperactivity disorder (ADHD) or other mental health difficulties including depression, anxiety, bipolar disorder, and obsessive compulsive disorder. Learning disabilities are twice as common in children with chronic health conditions.1,4,5
LEARNING DISABILITY ASSESSMENT
Medical conditions
The medical evaluation for suspected learning disability must be tailored to rule out obvious underlying or associated medical issues. Fetal alcohol syndrome, dysmorphisms, other syndromes, and apparent genetic causes should be ruled out.
Vision and hearing screens should be ordered and patients should be assessed for other potential sensory impairments that may resemble features of a learning disability. Medications such as anticonvulsants may have side effects that can cause learning difficulties and in older children, substance abuse must be ruled out.
Risk factors
A medical history should identify risk factors for learning disabilities. These include prematurity, low birth weight, early-life malnutrition, poverty and under-stimulating environments, head injury, epilepsy, and chronic health conditions. A family history of learning disabilities, including dyslexia or other learning disabilities, attention deficit, memory difficulty, and dropping out of school, are also risk factors.6
Early warning signs
Early warning signs of learning disability are listed in Table 1. Speech delay is particularly important to assess and parents should be asked about the child’s history of acquiring language. Children with problems discriminating sounds may present with difficulty in articulation.
Asking parents whether the child has trouble rhyming words, learning song lyrics, or carrying a tune is often helpful. For example, a child may be able to recite the words to “Happy Birthday to You” but cannot sing it. These questions provide information about ability to memorize words, follow directions, recite words back, and can indicate possible speech or hearing difficulties.
Written language ability can be assessed with pseudoword decoding or deciphering nonsense words based on phonemic awareness.
Although difficulty following directions can be an early warning sign, many children have problems in this area without a specific learning disability, especially if the direction is not in accordance with the level of neurological development (ie, complex instructions given to a younger child).
Fine motor skill impairment can be observed when children cannot easily hold utensils, button or buckle clothing, or manipulate small objects such as pencils and crayons. However, the ability to manipulate small objects should not rule out learning disability in institutionalized children or those from larger families, where small motor skills and independent dressing develop earlier. Other warning signs may be better indicators in these children.
Impaired visual-spatial processing may be manifested in a younger child as difficulty matching shapes and in an older child or adolescent as inability to copy information from a smart-board or whiteboard onto paper. Learning disabilities also may present as difficulty with processing of visual and auditory information.
Executive function
Learning disabilities can affect working memory and processing speed, which are basic cognitive processes subservient to the higher-order executive functions. The prefrontal cortex does not start to fully develop until a child is 7 to 8 years old. Impairment in this area may present as difficulties with time management, organization, or losing things. Those with right hemisphere involvement may have nonverbal learning disabilities exhibited as difficulty understanding math and word problems, and difficulty with perceptual reasoning. For example, the child may be able to repeat information in a rote manner but not grasp the meaning of what is said. This is sometimes termed a “cocktail personality,” in which a child’s conversation becomes nonsensical.
Nonverbal learning disabilities also are often seen in those with fetal alcohol syndrome or other fetal alcohol spectrum disorders such as alcohol-related neurodevelopmental disorder.
Attention deficit hyperactivity disorder
Learning disorders appear to have an established association with ADHD. Children with ADHD are twice as likely to have dyslexia, and, conversely, children with dyslexia are twice as likely to have ADHD. It is therefore difficult to establish which condition is primary. Did the ADHD behavior precede the dyslexia and accentuate a reading difficulty? Perhaps the dyslexia was primary, which led to inattentiveness on account of the inability to decipher words.
For these reasons, psychological assessments should be performed in a timely fashion to delineate the cause. It is easier for the general pediatrician to screen for attention problems than for dyslexia. Validated tests that screen for reading disorders in 3- to- 5-year-old children are not a routine part of well-child care.
SCHOOL SUPPORT
The IDEA requires that public schools assess children to determine their needs and provide the necessary support to address those needs.5 The goal is to ensure that all children receive free and appropriate education.
Assessment types
School districts’ assessments vary, but they are required to evaluate all areas of suspected disability, including during all parts of a school day, and to be carried out in a nonrestrictive environment (ie, educated in the regular classroom the student would attend if not disabled). The objective is to determine whether a child is eligible for an individualized education plan (IEP).
Schools have two options for learning disability assessment. The most common is a psychoeducational evaluation that includes cognitive and achievement assessment. Time limits for completing these assessments vary by state.
The alternative is to provide a response to intervention (RTI) approach. According to the National Center on RTI, “schools identify students at risk for poor learning outcomes, monitor student progress, provide evidence-based interventions, and adjust the intensity and nature of those interventions depending on a student’s responsiveness, and identify students with learning disabilities or other disabilities.”7 With RTI, there are varying levels of intensity, which may result in undue delays in education as a result of the observation period prior to intervention.
Any assessment requires evaluation of speech, language, and mathematics by a qualified professional, but the school is not required to do psychological or educational assessment. The role of school systems is not to provide comprehensive mental health support for students.
Individualized education plans
If an assessment finds a learning disability currently covered by IDEA (Table 2) and the disability affects effective educational progress, the school must develop an IEP for the student.
An IEP is a written contract outlining specific goals and measurable outcomes. It may include school placement determination and specific services like occupational therapy, physical therapy, speech, and/or special education services. The outcomes of an IEP can vary widely from state to state.
504 plans
When an assessment finds a covered disability but the disability is determined not to be a cause of educational impairment in terms of the child’s functioning in the school, the child will not qualify for an IEP but may be eligible for a 504 plan. Typically, a 504 plan involves making appropriate accommodation such as classroom seating location, homework modifications, and testing modifications.
Disagreement
There are options when the family and school disagree on the assessment outcome or the extent of an IEP plan. It is usually beneficial for the family to accept the IEP so that something is in place for the child while attempts are made to resolve the issue. In some cases, the family may choose to pursue their state-specific appeals process or mediation and/or to proceed to litigation. They also have the right to pursue independent assessment of their child’s suspected learning disability; however, this is an out-of-pocket expense that may not be covered by health insurance. Furthermore, the school is not required to accept independent assessor results or recommendations.
There may be benefits from independent neuropsychological evaluations because most school districts do not have access to neuropsychologists. Neuropsychological evaluations can provide a detailed assessment of higher-level cognitive abilities, such as executive function, memory, visual-spatial processing, visual-motor processing, language function, effort, and attention.
THE PEDIATRICIAN’S ROLE
School communication
The pediatrician can play a key role in requesting the initial multifactorial learning disability assessment on behalf of the family. Cleveland Clinic has template letters available for both the parents and the pediatrician to send to the school that can be adapted (Figure 1). Both should state the suspected learning disability ing disabilities and problems and should be addressed to the school principal.
Pediatricians can also communicate with the teacher about classroom strategies before an IEP or 504 Plan is determined, in order to help set the context of what may be coming. Surprisingly, many teachers are unfamiliar with requirements made for learning-disabled students, such as the benefits of seating the child toward the front of a class.
Talk to the child
The pediatrician should emphasize to the child that everyone learns differently and in a way best suited to him or her. The child should know that everyone’s brain works differently, and every child should try to work hard at school because it is their job in life at that age. Children can relate to an analogy that the brain is like a computer, with some models being faster than others and analyzing data differently.
Parents can help children build on their natural strengths and talents despite the learning disability. Point out that some children are good at math, others at reading, and some mainly excel at sports or the arts. It may be helpful to provide real-life examples of people who are successful despite learning disability, such as a celebrity with dyslexia.
Talk to the parents/guardians
Parents/guardians need to know that learning disability is not the result of poor parenting. Moreover, emphasize that the child is not lazy or stupid and that the condition can be very exhausting and frustrating for the child. Their child will have good and bad days, much like they do at their own work. Patience, rather than force, should be stressed.
Encourage parents to find alternative ways to teach their child that make it easier for them to learn. Online education programs may serve as beneficial supplements for these children, and field trips can provide more hands-on learning. In addition, talk to parents about the need for additional, independent testing and be able to refer them to appropriate sources for such testing as well as to neuropsychological resources, when warranted.
CONCLUSION
As families increasingly turn to pediatricians to address learning disabilities and problems children are having at school, physicians need to understand the various diagnoses and be able to assist with proper assessments. While schools must provide modifications when a diagnosis is made, there is sometimes disagreement about what the specific learning disability is and its extent of involvement in the child’s education. Diagnosing and addressing learning disability early can lessen various behavioral problems, help prevent dropping out of school, and enhance life outcomes for the child.
Learning disabilities can negatively affect the child, family, school, and, ultimately, society. Approximately 10% of US children have a learning disability.1 Unfortunately, learning disabilities are often unaddressed, under-addressed, or incorrectly addressed by family and schools.
Pediatricians are well positioned to address these concerns, refer for screenings and diagnoses, and provide additional support. This requires knowledge and skills to identify the risk factors for learning disabilities, recognize the early warning signs, and apply the appropriate diagnostic tools. Additionally, primary care pediatricians can support families with referrals to appropriate healthcare specialists and by communicating with patients’ schools.
LEARNING DISABILITIES DEFINED
There is no universal consensus regarding what constitutes a learning disability. The American Pediatrics Association defines specific learning disorder as reading, written expression, or mathematics skills that are substantially lower than expected for the individual’s age, measured intelligence, and age-appropriate education level or when achievement falls below a set standard.2
The Individuals with Disabilities Education Act (IDEA),3 which governs considerations schools must make for learning-disabled students, more broadly defines specific learning disability as impairment in one or more of the following: math, understanding or using written or spoken language, information processing, memory, and reading. Specific reading impairments include dyslexia, orthographic impairment (inability to memorize words), and hyperlexia disorder (comprehension difficulties). The IDEA also includes conditions such as perceptual disabilities, brain injury, minimal brain dysfunction, and developmental aphasia as learning disabilities.
EPIDEMIOLOGY
Approximately 10% of children in the United States have a learning disability. Of those affected, 40.7% have a learning disability in reading, language, math, information processing, or memory. Speech or language impairments affect 18.5%, of which dyslexia is the most common disability, affecting up to 80%. Mental retardation affects 7.4%, and 6.4% have serious emotional disturbances that prevent learning. In addition, up to 35% of those with a learning disorder have comorbid attention deficit hyperactivity disorder (ADHD) or other mental health difficulties including depression, anxiety, bipolar disorder, and obsessive compulsive disorder. Learning disabilities are twice as common in children with chronic health conditions.1,4,5
LEARNING DISABILITY ASSESSMENT
Medical conditions
The medical evaluation for suspected learning disability must be tailored to rule out obvious underlying or associated medical issues. Fetal alcohol syndrome, dysmorphisms, other syndromes, and apparent genetic causes should be ruled out.
Vision and hearing screens should be ordered and patients should be assessed for other potential sensory impairments that may resemble features of a learning disability. Medications such as anticonvulsants may have side effects that can cause learning difficulties and in older children, substance abuse must be ruled out.
Risk factors
A medical history should identify risk factors for learning disabilities. These include prematurity, low birth weight, early-life malnutrition, poverty and under-stimulating environments, head injury, epilepsy, and chronic health conditions. A family history of learning disabilities, including dyslexia or other learning disabilities, attention deficit, memory difficulty, and dropping out of school, are also risk factors.6
Early warning signs
Early warning signs of learning disability are listed in Table 1. Speech delay is particularly important to assess and parents should be asked about the child’s history of acquiring language. Children with problems discriminating sounds may present with difficulty in articulation.
Asking parents whether the child has trouble rhyming words, learning song lyrics, or carrying a tune is often helpful. For example, a child may be able to recite the words to “Happy Birthday to You” but cannot sing it. These questions provide information about ability to memorize words, follow directions, recite words back, and can indicate possible speech or hearing difficulties.
Written language ability can be assessed with pseudoword decoding or deciphering nonsense words based on phonemic awareness.
Although difficulty following directions can be an early warning sign, many children have problems in this area without a specific learning disability, especially if the direction is not in accordance with the level of neurological development (ie, complex instructions given to a younger child).
Fine motor skill impairment can be observed when children cannot easily hold utensils, button or buckle clothing, or manipulate small objects such as pencils and crayons. However, the ability to manipulate small objects should not rule out learning disability in institutionalized children or those from larger families, where small motor skills and independent dressing develop earlier. Other warning signs may be better indicators in these children.
Impaired visual-spatial processing may be manifested in a younger child as difficulty matching shapes and in an older child or adolescent as inability to copy information from a smart-board or whiteboard onto paper. Learning disabilities also may present as difficulty with processing of visual and auditory information.
Executive function
Learning disabilities can affect working memory and processing speed, which are basic cognitive processes subservient to the higher-order executive functions. The prefrontal cortex does not start to fully develop until a child is 7 to 8 years old. Impairment in this area may present as difficulties with time management, organization, or losing things. Those with right hemisphere involvement may have nonverbal learning disabilities exhibited as difficulty understanding math and word problems, and difficulty with perceptual reasoning. For example, the child may be able to repeat information in a rote manner but not grasp the meaning of what is said. This is sometimes termed a “cocktail personality,” in which a child’s conversation becomes nonsensical.
Nonverbal learning disabilities also are often seen in those with fetal alcohol syndrome or other fetal alcohol spectrum disorders such as alcohol-related neurodevelopmental disorder.
Attention deficit hyperactivity disorder
Learning disorders appear to have an established association with ADHD. Children with ADHD are twice as likely to have dyslexia, and, conversely, children with dyslexia are twice as likely to have ADHD. It is therefore difficult to establish which condition is primary. Did the ADHD behavior precede the dyslexia and accentuate a reading difficulty? Perhaps the dyslexia was primary, which led to inattentiveness on account of the inability to decipher words.
For these reasons, psychological assessments should be performed in a timely fashion to delineate the cause. It is easier for the general pediatrician to screen for attention problems than for dyslexia. Validated tests that screen for reading disorders in 3- to- 5-year-old children are not a routine part of well-child care.
SCHOOL SUPPORT
The IDEA requires that public schools assess children to determine their needs and provide the necessary support to address those needs.5 The goal is to ensure that all children receive free and appropriate education.
Assessment types
School districts’ assessments vary, but they are required to evaluate all areas of suspected disability, including during all parts of a school day, and to be carried out in a nonrestrictive environment (ie, educated in the regular classroom the student would attend if not disabled). The objective is to determine whether a child is eligible for an individualized education plan (IEP).
Schools have two options for learning disability assessment. The most common is a psychoeducational evaluation that includes cognitive and achievement assessment. Time limits for completing these assessments vary by state.
The alternative is to provide a response to intervention (RTI) approach. According to the National Center on RTI, “schools identify students at risk for poor learning outcomes, monitor student progress, provide evidence-based interventions, and adjust the intensity and nature of those interventions depending on a student’s responsiveness, and identify students with learning disabilities or other disabilities.”7 With RTI, there are varying levels of intensity, which may result in undue delays in education as a result of the observation period prior to intervention.
Any assessment requires evaluation of speech, language, and mathematics by a qualified professional, but the school is not required to do psychological or educational assessment. The role of school systems is not to provide comprehensive mental health support for students.
Individualized education plans
If an assessment finds a learning disability currently covered by IDEA (Table 2) and the disability affects effective educational progress, the school must develop an IEP for the student.
An IEP is a written contract outlining specific goals and measurable outcomes. It may include school placement determination and specific services like occupational therapy, physical therapy, speech, and/or special education services. The outcomes of an IEP can vary widely from state to state.
504 plans
When an assessment finds a covered disability but the disability is determined not to be a cause of educational impairment in terms of the child’s functioning in the school, the child will not qualify for an IEP but may be eligible for a 504 plan. Typically, a 504 plan involves making appropriate accommodation such as classroom seating location, homework modifications, and testing modifications.
Disagreement
There are options when the family and school disagree on the assessment outcome or the extent of an IEP plan. It is usually beneficial for the family to accept the IEP so that something is in place for the child while attempts are made to resolve the issue. In some cases, the family may choose to pursue their state-specific appeals process or mediation and/or to proceed to litigation. They also have the right to pursue independent assessment of their child’s suspected learning disability; however, this is an out-of-pocket expense that may not be covered by health insurance. Furthermore, the school is not required to accept independent assessor results or recommendations.
There may be benefits from independent neuropsychological evaluations because most school districts do not have access to neuropsychologists. Neuropsychological evaluations can provide a detailed assessment of higher-level cognitive abilities, such as executive function, memory, visual-spatial processing, visual-motor processing, language function, effort, and attention.
THE PEDIATRICIAN’S ROLE
School communication
The pediatrician can play a key role in requesting the initial multifactorial learning disability assessment on behalf of the family. Cleveland Clinic has template letters available for both the parents and the pediatrician to send to the school that can be adapted (Figure 1). Both should state the suspected learning disability ing disabilities and problems and should be addressed to the school principal.
Pediatricians can also communicate with the teacher about classroom strategies before an IEP or 504 Plan is determined, in order to help set the context of what may be coming. Surprisingly, many teachers are unfamiliar with requirements made for learning-disabled students, such as the benefits of seating the child toward the front of a class.
Talk to the child
The pediatrician should emphasize to the child that everyone learns differently and in a way best suited to him or her. The child should know that everyone’s brain works differently, and every child should try to work hard at school because it is their job in life at that age. Children can relate to an analogy that the brain is like a computer, with some models being faster than others and analyzing data differently.
Parents can help children build on their natural strengths and talents despite the learning disability. Point out that some children are good at math, others at reading, and some mainly excel at sports or the arts. It may be helpful to provide real-life examples of people who are successful despite learning disability, such as a celebrity with dyslexia.
Talk to the parents/guardians
Parents/guardians need to know that learning disability is not the result of poor parenting. Moreover, emphasize that the child is not lazy or stupid and that the condition can be very exhausting and frustrating for the child. Their child will have good and bad days, much like they do at their own work. Patience, rather than force, should be stressed.
Encourage parents to find alternative ways to teach their child that make it easier for them to learn. Online education programs may serve as beneficial supplements for these children, and field trips can provide more hands-on learning. In addition, talk to parents about the need for additional, independent testing and be able to refer them to appropriate sources for such testing as well as to neuropsychological resources, when warranted.
CONCLUSION
As families increasingly turn to pediatricians to address learning disabilities and problems children are having at school, physicians need to understand the various diagnoses and be able to assist with proper assessments. While schools must provide modifications when a diagnosis is made, there is sometimes disagreement about what the specific learning disability is and its extent of involvement in the child’s education. Diagnosing and addressing learning disability early can lessen various behavioral problems, help prevent dropping out of school, and enhance life outcomes for the child.
- Altarac M, Saroha E. Lifetime prevalence of learning disability among US children. Pediatrics 2007; 119(suppl 1):S77–S83.
- American Psychiatric Association. Diagnostic and Statistical Manual of Mental Disorders. 5th ed. Arlington, VA: American Psychiatric Association; 2013.
- Building the Legacy: IDEA 2004. U.S. Department of Education website. http://idea.ed.gov/. Accessed July 6, 2015.
- Pastor PN, Reuben CA. Diagnosed attention deficit hyperactivity disorder and learning disability: United States, 2004–2006. Vital Health Stat 10 2008; 237:1–14. http://www.cdc.gov/nchs/data/series/sr_10/Sr10_237.pdf. Accessed July 6, 2015.
- U.S. Department of Education, Office of Special Education and Rehabilitative Services. 29th Annual Report to Congress on the Implementation of the Individuals with Disabilities Education Act, 2007, vol 1. Washington, DC; 2010. http://www2.ed.gov/about/reports/annual/osep/2007/parts-b-c/29th-vol-1.pdf. Accessed July 6, 2015.
- National Joint Committee on Learning Disabilities. Learning Disabilities and Young Children: Identification and Intervention (technical report). October 2007. http://www.asha.org/policy/TR2007-00307/. Accessed July 6, 2015.
- Response to intervention (RTI). Center for Parent Information and Resources website. http://www.parentcenterhub.org/repository/rti/. Updated August 2012. Accessed July 6, 2015.
- Altarac M, Saroha E. Lifetime prevalence of learning disability among US children. Pediatrics 2007; 119(suppl 1):S77–S83.
- American Psychiatric Association. Diagnostic and Statistical Manual of Mental Disorders. 5th ed. Arlington, VA: American Psychiatric Association; 2013.
- Building the Legacy: IDEA 2004. U.S. Department of Education website. http://idea.ed.gov/. Accessed July 6, 2015.
- Pastor PN, Reuben CA. Diagnosed attention deficit hyperactivity disorder and learning disability: United States, 2004–2006. Vital Health Stat 10 2008; 237:1–14. http://www.cdc.gov/nchs/data/series/sr_10/Sr10_237.pdf. Accessed July 6, 2015.
- U.S. Department of Education, Office of Special Education and Rehabilitative Services. 29th Annual Report to Congress on the Implementation of the Individuals with Disabilities Education Act, 2007, vol 1. Washington, DC; 2010. http://www2.ed.gov/about/reports/annual/osep/2007/parts-b-c/29th-vol-1.pdf. Accessed July 6, 2015.
- National Joint Committee on Learning Disabilities. Learning Disabilities and Young Children: Identification and Intervention (technical report). October 2007. http://www.asha.org/policy/TR2007-00307/. Accessed July 6, 2015.
- Response to intervention (RTI). Center for Parent Information and Resources website. http://www.parentcenterhub.org/repository/rti/. Updated August 2012. Accessed July 6, 2015.
