Practical Management Of The Child With Learning Problems

Laura L. Bailet, Ph.D.
Laura L. Bailet, Ph.D. is a Neuro-Cognitive Specialist with the
Division of Neurology at Nemours Children's Clinic, Jacksonville.

The pediatrician or family physician is often the first professional parents contact when they become concerned their child may have a learning problem. The physician thus has the opportunity to play a critical role in guiding parents toward appropriate evaluation and intervention. Many aspects of primary care are central to effective identification and management of childhood learning problems. For example, any child experiencing a learning or school performance problem should have a vision and hearing screen. A detailed history of the current problem, placed within the context of the child's medical, developmental and family history, provides important guideposts for determining the type and timing of assessment needed to pinpoint the problem.

Many medical conditions predispose children to learning problems, the presence of which should trigger a referral for comprehensive medical or psychological evaluation, or both. Table 1 lists medical conditions that are frequently associated with long-term learning problems and cognitive deficits. Children with these risk factors should be monitored closely during early childhood. If significant problems emerge, comprehensive psychological and educational evaluation and intervention should be initiated expeditiously. Similarly, children whose parents, siblings, or extended family members have a history of learning problems, such as dyslexia, are at increased risk for learning problems and should be closely monitored.

Types Of Learning Disorders And Diagnostic And Management Strategies

There are many types of learning disorders, and the diagnostic categories can be confusing for a number of reasons. First, the symptoms of most learning disorders overlap, making differential diagnosis difficult. Second, there is a high incidence of co-morbidity among learning and behavioral disorders. Third, many of the symptoms are subjective, leading professionals and the general public to feel that these diagnoses are "in the eye of the beholder." Fourth, for many children, the manifestations of their learning disorders change over time. Although this can aid the clinician in diagnosis if he or she follows the child for several years, it makes initial diagnosis more difficult. The most common learning disorders are described below, with hallmark characteristics, types of evaluations, and most appropriate intervention approaches discussed.

Speech/Language Disorder

This occurs in perhaps 10-15% of preschool and school-aged children and thus is very common.¹ Language disorders can be broadly classified as either a language comprehension (receptive) disorder or language expression (expressive) disorder, although many children with developmental language disorder have both. Language disorders may affect comprehension and expression of individual words or sentences. As children become older, their language disorder may affect more abstract verbal reasoning skills, which often is one source of their school difficulty. Problems with language semantics (word meaning), and pragmatics (the socially appropriate use of language to indicate thoughts and needs and converse easily with others), are frequently present in children with autism but may occur with other types of learning disorders.

Many children have only a speech disorder, such as impaired pronunciation or stuttering. They are less likely to experience significant learning problems than children with broader language impairment. A history of significant language comprehension disorder in the preschool years is a strong predictor of school learning difficulties and of placement in special education programs. Physicians therefore should assess what a young child understands, as well as what he or she says. As perhaps 50% of children with language disorder will experience significant school difficulty, they should be monitored closely, at least during the early elementary grades. Early involvement with a speech/language pathologist for evaluation and therapy is recommended, particularly for those youngsters showing significant language comprehension deficits, severe and persistent speech pronunciation deficits, or both.

Learning Disabilities

A learning disability (LD) is currently defined as a significant, persistent deficit in one or more academic achievement areas, including reading, writing, and mathematics. Specific deficits in language and reasoning skills also may be considered a learning disability. A conservative estimate is that about 5% to 10% of children have LD.² Tremendous progress has been made in understanding and treating the most common learning disability, dyslexia. Dyslexia refers to reading and spelling disability and is usually associated with deficits in specialized language skills that enable us to perceive and mentally manipulate individual letter sounds within words. These skills are collectively referred to as phonological processing skills, which have been shown to comprise the core deficit for most individuals with dyslexia. The main features of dyslexia are shown in Table 2. In most cases, dyslexia is a language-based disorder. Remedial techniques that explicitly address critical language units, including letter sounds, syllables and words are likely to be most successful long-term.

Early identification of children at risk for dyslexia is now possible due to the widespread availability of brief phonological processing tests. Our increased awareness of genetic and developmental factors predisposing a child to dyslexia should facilitate timely assessment. To diagnose LD, a child needs comprehensive psychological and educational testing to identify patterns of learning strengths and deficits. Such assessment can also identify co-morbid conditions, such as language disorder, attention-deficit/hyperactivity disorder (ADHD), anxiety or depression that need to be treated concomitantly with the LD.

Several excellent teaching programs designed to improve phonological processing skills, reading, and spelling are available and can be used in either individual or group instruction. Explicit training in phonological processing and phonics has been shown to result in the best gains long-term for most children with dyslexia. Although it is rare to completely "cure" dyslexia, the long-term prognosis is better when appropriate intervention is initiated early in elementary school. Family consultation with a psychologist who is knowledgeable about LD diagnosis, teaching approaches, and educational options is often beneficial, as it may save families time and money in finding the best services for their child's needs.

Mental Retardation

Mental retardation occurs in approximately 3% of the population and is defined as having intelligence and adaptive functioning two or more standard deviations below normal. It is diagnosed using psychological and educational tests similar to those used for an LD evaluation. A mentally retarded child's scores on both an individual intelligence test and a measure of adaptive functioning are less than a standard score of 70 (mean score is 100; standard deviation is 15 or 16). Table 3 shows a standard score scale, corresponding percentile scores, and classifications. There are several categories of mental retardation, from to mild to profound, which reflect a significant range of functionality.

Most mentally retarded youngsters require long-term special education. Some mainstreaming into the regular curriculum may be appropriate for those with mild mental retardation. Most school systems avoid the term "mental retardation" because of associated stigma and instead use "mental handicap" or "intellectually deficient." Various social and vocational services are available in the community for children and adults with mental retardation, and families should be encouraged to tap into these services when appropriate.

Developmental delay is a term frequently used by physicians to describe children who are slower in attaining early milestones. Although it is an appropriate and helpful term in some situations, it often misleads families into thinking that the child will eventually "catch up" to normal. Physicians need to be clear with families that young children with developmental delay may not catch up and instead may show chronic learning and adaptive deficits. On the other hand, some children show delays at a young age but eventually normalize, particularly if given early intervention. For children who qualify based on diagnostic assessment criteria, services are available from birth to three years through the Early Intervention Program (EIP), and from age three years on, through public school systems.

Pervasive Developmental Disorder/Autism

Pervasive developmental disorder (PDD) is a broad class of disorders for which autism is the most well known subtype. Current incidence estimates indicate that approximately 1 child per 1,000 has autism,³ although recent studies suggest a higher incidence rate (1:500), which may reflect a growing awareness of milder cases with normal intelligence. Autism is characterized by significant impairment in social/emotional interaction, poor language and communication skills, and repetitive, stereotypic patterns of behavior or interests. About 75% of children with autism also have mental retardation. Asperger's syndrome is a subtype of PDD and refers to individuals with poor social relatedness and markedly restricted and unusual patterns of interests or behaviors. Individuals with Asperger's syndrome differ from those with autism in that their basic language skills are normal, and there is no clinically significant history of language impairment. The autism spectrum disorders are extensively described elsewhere in this journal. Because their deficits are subtler, children with mild autism or Asperger's syndrome may not be diagnosed as preschoolers. The physician thus should be alert to these diagnostic possibilities for school-age children.

Attention-Deficit/Hyperactivity Disorder

Attention-Deficit/ Hyperactivity Disorder (ADHD) is characterized by poor sustained attention, impulsive and distractible behavior, and sometimes hyperactivity. It is one of the most controversial diagnoses in existence. Public mistrust of professionals who make the diagnosis and fear of stimulant medication, particularly methylphenidate, are high. Physicians should exercise caution in making the ADHD diagnosis and consider the many other conditions that may mimic some aspects of it. (See Table 4). Approximately 3% to 5% of school-age children have AD-HD,⁴ and perhaps 60% or more of those children also have academic achievement problems.⁵

In order to make a diagnosis of ADHD, it is essential that the child display the core symptoms from an early age, for at least 6 months, and in more than one setting.⁶ The symptoms must substantially impair functioning in one or more major activities, such as academic achievement. The primary means of diagnosing ADHD involves taking a detailed developmental, behavioral, and family history, and asking parents and teachers to complete behavior rating scales. It is critical to compare a child's possible ADHD symptoms with behaviors that are typical of others the same age. This will allow differentiation between what is truly a disorder, versus the sometimes problematic but normal behavior of most children. Psychological and educational tests can be helpful in identifying intelligence level, learning disabilities, and other psychiatric conditions that may be causing the child's behavioral problems or that co-exist with ADHD.

The most effective intervention typically involves stimulant medication, parent training in behavior management, and minor educational accommodations in the regular classroom. For those with severe ADHD or concomitant LD, special education may be necessary. Children who fail to respond as expected to stimulant medication and show a more complex symptom pattern often benefit from a psychiatric consultation to further delineate the nature of the problem and consider a wider range of medication options.

Other Behavioral And Emotional Disorders

Many childhood behavioral and emotional disorders manifest themselves as school performance problems, inattention, and hyperactivity, which may be the symptoms that a parent first discusses with a physician. Some of the more common disorders in this category include anxiety, depression, oppositional-defiant disorder, conduct disorder, and obsessive-compulsive disorder. Many children referred for possible ADHD in fact display one or more of these other diagnoses, either with or without ADHD or LD. Comprehensive psychological and educational evaluation in conjunction with psychiatric consultation are needed to identify all the pertinent symptoms, diagnoses, and intervention strategies. Treatment tends to be most successful with ongoing individual and family therapy and psychiatric support.

Summary

Many types of developmental, learning, behavioral, and emotional disorders can impair a child's ability to function as expected. Parents often seek the advice of their physician as a first step in addressing such problems. Timely psychological and educational evaluation is critical for correct diagnosis and determination of services that are likely to be most effective. As these disorders tend to be chronic, periodic reassessment of the child's strengths and weaknesses is essential to optimize services and long-term outcome. Federal laws have increased services and opportunities for individuals with disabilities. For most, the future is much brighter if families can access services early and obtain ongoing evaluation and support. Physicians provide a critical link to such services and thus have both the opportunity and obligation to address developmental, behavioral, and emotional status in their patients and guide families toward appropriate evaluation and intervention.

REFERENCES

1. Cantwell D, Baker L. Developmental Speech and Language Disorders. New York: Guilford Press; 1987.
2. Jordan NC, Goldsmith-Phillips J. Learning Disabilities: New Directions For Assessment and Intervention. Boston: Allyn and Bacon; 1994.
3. Tuchman RF. Autism: delineating the spectrum. International Pediatrics. 1991;6:161-169.
4. Cantwell DP. Attention deficit disorder: a review of the past 10 years. J Am Acad Child Adolesc Psychiatry. 1996; 35:978-987.
5. Barkley R. Hyperactive Children. New York: Guilford Press; 1981.
6. American Psychiatric Association. Diagnostic and Statistical Manual of Mental Disorders. 4^th ed. Washington, D.C.: American Psychiatric Association; 1994:78-85.

Jacksonville Medicine / March, 2000

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