| Learning Problems | ||
Paul P. Wang
| Database Differential Diagnosis Approach to the Patient Data Gathering Physical Examination Laboratory Aids Common Questions and Answers Bibliography |
| DATABASE | ||
DEFINITION
A learning problem exists whenever a child falls behind in school or shows a deterioration from a previous level of performance. Psychosocial factors account for many learning problems, but other learning problems have a direct medical basis. The terms learning disorder or learning disability refer to conditions in which academic achievement is substantially below that expected for age, schooling, and level of intelligence.
| DIFFERENTIAL DIAGNOSIS | ||
CONGENITAL/ANATOMICAL
INFECTIOUS
TOXIC
GENETIC/METABOLIC
MISCELLANEOUS
NEUROPSYCHIATRIC DISORDERS
| APPROACH TO THE PATIENT | ||
GENERAL GOAL
Determine whether the learning problems are primary, or whether they result from another medical or psychosocial condition. The pediatrician should coordinate the appropriate medical, psychiatric, and/or psychoeducational evaluation, with consultation as indicated. Early identification of learning problems helps to prevent the cascade of negative consequences triggered by poor academic achievement.
phase 1: Identify and address medical factors that may affect learning (e.g., sensory impairments, lead intoxication, absence seizures, iatrogenic interventions). Consider subtle genetic syndromes (e.g., Fragile X syndrome in girls) that may cause learning problems without causing other major medical abnormalities.
phase 2: Screen for psychiatric conditions, and for social and environmental factors that may be associated with learning problems. Psychosocial stresses may exacerbate learning difficulties, or be a primary etiologic factor. If indicated, refer to appropriate consultants.
phase 3: For patients with learning problems that are suspected to be primary (e.g., reading or math disability, attention deficit disorder), a complete psychoeducational evaluation is indicated. Referral may be made to the school system, or to private professionals. Medical treatment of attention deficit may be undertaken by the primary care physician or by subspecialists.
| DATA GATHERING | ||
HISTORY
Question: How and when does the child fail in daily academic
pursuits?
Significance: For specific learning disabilities, problems
may occur only in one class. For attention deficit, problems may be minimized
with one-on-one teaching.
Question: Deterioration in performance?
Significance:
Consider new pathophysiologic processes:
Question: Past medical history? Medications? Review of systems?
Psychosocial stresses?
Significance: Identify pre-existing factors
that may affect learning.
Question: Early milestones?
Significance: History of
language delays is common in children with reading disability.
Question: Family history?
Significance: Attention deficit
disorders and learning disorders often carry a heritable component.
HINTS FOR SCREENING
The child may be the only person who can provide important information on their reaction to the learning problems (anxiety, depression, etc.) and on family and school circumstances surrounding these problems. The latter must be addressed with the appropriate confidentiality.
| PHYSICAL EXAMINATION | ||
Finding: Abnormal growth parameters
Significance: May
indicate presence of chronic illness or genetic syndrome, or history of
neurologic injury.
Finding: Subtle dysmorphology
Significance: Possible
teratogenic fetal exposure or unidentified genetic syndrome.
Finding: Abnormal neurological examination
Significance: Any
focal signs demand additional evaluation. Soft signs (neuro-maturational signs)
are often present in children with learning problems, but are non-specific.
Finding: Abnormal audiology or vision
screening
Significance: May be direct cause of learning
problem.
| LABORATORY AIDS | ||
Test: Standardized behavior questionnaires
Significance:
Diagnosis of attention deficit disorder is critically dependent on input from
teachers and parents.
Test: Psychoeducational evaluation
Significance: These data
are necessary to establish the presence of a specific learning disability, and
to formulate intervention strategies.
Test: Lead level, thyroid functions, EEG
Significance: If
history is suggestive, must rule out these etiologies.
| COMMON QUESTIONS AND ANSWERS | ||
Q: What classroom accommodations can be made for children with
learning problems?
A: Depending of the nature of the problem, possible
accommodations include preferential seating, extra time for test-taking, use of
electronic word processors, provision of written rather than verbal
instructions, tutoring, resource room assistance, and alternative classroom
placement.
Q: What is the difference between psychoeducational and
neuropsychological testing?
A: A typical psychoeducational evaluation
includes IQ and academic achievement testing, and behavioral assessment. This
testing must be performed individually, by a professional who can establish a
good rapport with the student. For most children, this testing is sufficient to
identify learning disabilities and to prescribe educational remedies. For
children who do not respond to first-line educational interventions,
neuropsychological testing may help to define specific cognitive strengths and
weaknesses that must be accounted for in working with the student.
Q: How can the family obtain a complete school
evaluation?
A: Regulations vary from state to state. Parents can
usually start by writing to the principal of their local public school to
request a complete evaluation and stating the reasons for their request.
(Specific information for each state can be obtained from the National
Information Center for Children and Youth with Disabilities (800-695-0285; http://www.nichcy.org./)
Indications for Referral
Clinical Pearls
| BIBLIOGRAPHY | ||
Beitchman JH, Young AR. Learning disorders with a special emphasis on reading disorders: a review of the past 10 years. J Am Acad Child Adolesc Psychiatry 1997;36(8):1020–1032.
Levy SE. Pediatric evaluation of the child with developmental delay. Child Adolesc Psychiatr Clin N Am 1996;5(4):809–826.
Reiff MI. Adolescent school failure: failure to thrive in adolescence. Pediatr Rev 1998;19(6):199–207.
Resnick MB, Gomatam SV, Carter RL, et al. Educational disabilities of neonatal intensive care graduates. Pediatrics 1998;102(2 Pt 1):308–314.
Shaywitz SE. Dyslexia. N Engl J Med 1998;338(5):307–312.
Copyright
© 2000 Lippincott Williams & Wilkins
M. William
Schwartz, Louis M. Bell, Jr., Peter M. Bingham, Esther K. Chung, David F.
Friedman and Andrew E. Mulberg, The 5 Minute Pediatric Consult