7/23/2019 Learning Problems.pdf

http://slidepdf.com/reader/full/learning-problemspdf 1/5

Learning Problems

Basics

DESCRIPTION

• Learning disorders, or learning disabilities, are defined in the Diagnostic and Statistical Manual of

Mental Disorders, 4th edition (DSM-I! as a"ade#i" a"hie$e#ent that is s%bstantiall& belo' the le$el

e)e"ted for age, s"hooling, and general intelle"t%al abilit&, and that "annot be a""o%nted for b&

)s&"hoso"ial fa"tors*

+* In ritish #edi"al literat%re, learning disabilit&. is often s&non&#o%s 'ith #ental

retardation*.

• Learning disabilit& #a& affe"t reading, 'riting, s)elling, or #ath*

•  /n& gi$en "hild #a& ha$e #ore than + learning disabilit&*

• Learning disabilities ha$e ne%robiologi" and geneti" roots*

• Reading disorder, 'hi"h is also 0no'n as dyslexia and is the #ost fre1%entl& diagnosed t&)e of

learning disorder, is "hara"teri2ed b& i#)air#ents in )honologi" )ro"essing*

EPIDEMIOLO3

Ps&"hiatri" "o#orbidit& is fre1%ent, either as a "o#)li"ation of learning )roble#s or as an etiologi" fa"tor in their

de$elo)#ent*

In"iden"e

Esti#ated in"iden"e 5+67 in s"hool-aged "hildren8

• T&)i"all& not e$ident %ntil a"ade#i" de#ands are )la"ed on affe"ted "hildren*

ETIOLO3

S)e"%lati$e etiologies ('idel& dis"%ssed b%t essentiall& %n)ro$en!8

• 9ood allergies

•   “De$elo)#ental o)to#etri". disorders

• E)os%re to food )reser$ati$es or s%gar 

Diagnosis

• 3eneral goal is to deter#ine 'hether the learning )roble#s res%lt fro# a )ri#ar& #edi"al or

)s&"hoso"ial "ondition* If no s%"h "ondition is identified, then the )atient #a& ha$e a s)e"ifi" learning

disabilit&*

• The )ediatri"ian also is in a good )osition to identif& so"ial and en$iron#ental fa"tors that #a& be

asso"iated 'ith learning )roble#s, and "an "oordinate the a))ro)riate #edi"al, )s&"hiatri", and:or

)s&"hoed%"ational e$al%ation, 'ith "ons%ltation as indi"ated*

• Earl& identifi"ation of learning )roble#s and a))ro)riate inter$ention hel) to )re$ent the "as"ade of

negati$e "onse1%en"es triggered b& )oor a"ade#i" a"hie$e#ent8

+* Phase +a8

• Identif& and address #edi"al fa"tors that #a& affe"t learning (e*g*, sensor&

7/23/2019 Learning Problems.pdf

http://slidepdf.com/reader/full/learning-problemspdf 2/5

i#)air#ents, lead intoi"ation, absen"e sei2%res, iatrogeni" inter$entions!*

• Consider s%btle geneti" s&ndro#es (e*g*, fragile ; s&ndro#e in girls! that #a&

"a%se learning )roble#s 'itho%t "a%sing other #a<or #edi"al abnor#alities*

=* Phase +b8

• S"reen for )s&"hiatri" "onditions and for so"ial and en$iron#ental fa"tors that

#a& be asso"iated 'ith learning )roble#s*

• Ps&"hoso"ial stresses #a& ea"erbate learning diffi"%lties or be a )ri#ar&

etiologi" fa"tor*

• If indi"ated, refer to a))ro)riate "ons%ltants*

>* Phase =8

• 9or )atients 'ith learning )roble#s that are s%s)e"ted to be )ri#ar& (i*e*,

s)e"ifi" learning disabilities!, a "o#)lete )s&"hoed%"ational e$al%ation is

indi"ated*

• If /D?D )resent, treat#ent #a& be dire"ted b& the )ri#ar& "are )h&si"ian or b&

a s%bs)e"ialist*

SI3NS /ND SMPTOMS

?istor&

•  /s0 'hen and ho' the "hild fails in his or her dail& a"ade#i" )%rs%its8

+* 9or s)e"ifi" learning disabilities, )roble#s #a& o""%r in onl& one "lass*

=* 9or attention defi"it, )roble#s #a& be broad based and #a& e#erge as "hildren #o$e into

#ore for#al dida"ti" settings*

>* @ith borderline #ental retardation or other "hroni" )roble#s, there #a& be a long histor& of de$elo)#ental "on"erns*

• If de"line in s"hool )erfor#an"e is re"ent or ne', "onsider ne' )atho)h&siologi" )ro"esses, s%"h as

)s&"hoso"ial iss%es, ne' $ision or hearing i#)air#ent, side effe"t fro# ne' #edi"ation, or

ne%rodegenerati$e disorder (rare!*

• Poor s"hool )erfor#an"e "o##onl& leads to de)ression, )oor self-estee#, and )ossible beha$ior

)roble#s*

• Past #edi"al histor&, #edi"ations, re$ie' of s&ste#s, )s&"hoso"ial stresses8

+* Identif& fa"tors that #a& affe"t learning*

=* Earl& lang%age dela&s are "o##on a#ong "hildren 'ith learning disorders*

• 9a#il& histor& #a& be )ositi$e for learning or attention )roble#s that are si#ilar to the "hildAs*

Ph&si"al Ea#

• S%btle d&s#or)holog&8 Ma& s%ggest the )resen"e of a geneti" s&ndro#e or a )attern of #alfor#ation

res%lting fro# teratogeni" fetal e)os%res (e*g*, al"ohol, )hen&toin!

•  /bnor#al ne%rologi" ea#ination8

7/23/2019 Learning Problems.pdf

http://slidepdf.com/reader/full/learning-problemspdf 3/5

+* /n& fo"al signs de#and additional e$al%ation*

=* Soft signs (ne%ro#at%rational signs! are often )resent in "hildren 'ith learning )roble#s,

b%t are nons)e"ifi"*

•  /bnor#al a%diolog& or $ision s"reening8 ision or hearing )roble#s #a& be dire"t "a%se of learning

)roble#*

TESTS

eha$ioral s"reening sho%ld be )erfor#ed, b%t no laborator& st%dies are ro%tinel& indi"ated* The histor& and

)h&si"al ea#ination #a& )ro$ide s)e"ifi" indi"ations for f%rther testing*

• Standardi2ed beha$ior 1%estionnaires8

+* Diagnosis of /DD is "riti"all& de)endent on in)%t fro# tea"hers and )arents*

=* Ps&"hiatri" "o#)li"ations, s%"h as de)ression, sho%ld also be "onsidered*

• Lead le$el, th&roid f%n"tions, 0ar&ot&)e, ?I testing, hearing and $ision testing, EE3, ne%roi#aging8

Ea"h of these "an be "onsidered if the histor& or )h&si"al ea# )ro$ide s)e"ifi" indi"ations*

• Ps&"hoed%"ational e$al%ation8

+* Co#)rehensi$e e$al%ation ser$es as the "ornerstone of diagnosis and ed%"ational

inter$ention*

=* Testing #%st be )erfor#ed indi$id%all& and sho%ld in"l%de general intelligen"e and

a"ade#i" a"hie$e#ent testing*

3. 9ederal la' re1%ires s"hools to )ro$ide "o#)rehensi$e e$al%ations on 'ritten re1%est b&

the )arents to the s"hool )rin"i)al* S)e"ifi" infor#ation for ea"h state "an be obtained fro#

the National Disse#ination Center for Children 'ith Disabilities (B66--

6=BF '''*ni"h"&*org!*

4* Man& "enters o%tside the s"hool s&ste# (e*g*, hos)ital-based "enters! also "ond%"t

e$al%ations of "hildren 'ith learning )roble#s*

• Ne%ro)s&"hologi" e$al%ation8 9or "hildren 'ho do not res)ond to first-line ed%"ational inter$entions,

#ore etensi$e ne%ro)s&"hologi" testing #a& el%"idate s)e"ifi" "ogniti$e strengths and 'ea0nesses

that #a& hel) in de$elo)ing an effe"ti$e ed%"ational )lan*

Iss%es for referral8

• Referrals to #edi"al and )s&"hologi" )rofessionals #a& be hel)f%l for both diagnosti" and thera)e%ti"

)%r)oses*

• @hen a s)e"ifi" #edi"al etiolog& is s%s)e"ted, the "hoi"e of s%bs)e"ialist for referral 'ill be "lear*

• @hen no s)e"ifi" etiolog& is a))arent, "onsider referral to a "lini"ian e)erien"ed 'ith learning

disabilities, 'ho #a& assist in "o#)rehensi$e diagnosti" for#%lation, )har#a"ologi" treat#ent 'hen

indi"ated, de$elo)#ental follo'-%), and ad$o"a"&*

Clini"al )earls8

• Co#orbidit& and s&#)to#ati" o$erla) are "o##on a#ong /D?D, s)e"ifi" learning disabilities, and

other )s&"hiatri" disorders8

+* St%dents 'ho ha$e a learning disabilit& or are de)ressed #a& sho' s&#)to#s of

7/23/2019 Learning Problems.pdf

http://slidepdf.com/reader/full/learning-problemspdf 4/5

inattention*

=* /"ade#i" or attention diffi"%lties #a& lead to s)iraling )s&"hologi" )roble#s, fro#

de)ression or da#aged self-estee# to "ond%"t disorder and s"hool dro)o%t*

• Nor#al attention and a"ti$it& in the )h&si"ianAs offi"e do not r%le o%t /D?D8

+* Man& "hildren 'ith /D?D sho' signifi"ant diffi"%lties 'ith inattention and distra"tibilit&, b%t

little h&)era"ti$it&*

=* E$en "hildren 'ith se$ere /D?D #a& a))ear attenti$e in the inti#idating and artifi"ial

#ilie% of the do"torAs offi"e or 'hen engaged in highl& #oti$ating and highl& reinfor"ing

"o#)%ter ga#es*

DI99ERENTI/L DI/3NOSIS

ChildrenAs s"hool )roble#s #a& res%lt fro# a s)e"ifi" learning disorder or #a& be the se"ondar& effe"t of so#e

other #edi"al or )s&"hoso"ial )roble#*

•  /D?D #a& )resent as a learning )roble#, es)e"iall& 'hen the inattenti$e and distra"tible s&#)to#s

of the diagnosis are greater than the h&)era"ti$e s&#)to#s*

+* Ma& be diffi"%lt to disting%ish fro# a learning disorder, and the = also #a& be fo%nd

"o#orbidl&

=* Caref%l )s&"hoed%"ational assess#ent #a& be needed to "larif& these diagnoses*

• Sensor& i#)air#ents8

+* ?earing or $ision i#)air#ents #a& "a%se learning )roble#s*

=* S"hool s"reening res%lts sho%ld be "onfir#ed in "hildren 'ith learning )roble#s*

• Ne%rologi"8

+* /bsen"e sei2%res and other non"on$%lsi$e e)ile)ti" disorders are #%"h less "o##on than /D?D b%t #a& #i#i" its s&#)to#s*

=* Nar"ole)s& also is asso"iated 'ith learning )roble#s*

>* Ne%rodegenerati$e disorders s%"h as Nie#ann-Pi"0 disease, adrenole%0od&stro)h&, "eroid

li)of%s"inosis, and s%ba"%te s"lerosing )anen"e)halitis #a& rarel& )resent as s"hool-age

learning )roble#s*

• Mental retardation8 In so#e "ases, borderline and #ild #ental retardation are not re"ogni2ed %ntil

s"hool entran"e*

• 3eneti"s8 So#e geneti" s&ndro#es #a& sho' s%btle d&s#or)holog& that is not noted %ntil learning

)roble#s arise* Ea#)les in"l%de8

+* Se "hro#oso#e ane%)loidies

=* 9ragile ; s&ndro#e in both bo&s and girls

>* Ne%rofibro#atosis

4* T%bero%s s"lerosis

* elo"ardiofa"ial:Di3eorge s&ndro#e

7/23/2019 Learning Problems.pdf

http://slidepdf.com/reader/full/learning-problemspdf 5/5

• N%tritional, toi"ologi", infe"tions8 Lead intoi"ation, "hroni" #aln%trition, iron

defi"ien"&, h&)oth&roidis#, and ?I infe"tion #a& ha$e insidio%s effe"ts on "ogniti$e f%n"tion*

• Iatrogeni" inter$entions8 Medi"al thera)ies #a& "o#)ro#ise learning abilitiesF an ea#)le is

treat#ent 'ith antie)ile)ti" dr%gs and other #edi"ations that affe"t "ognition*

• Ps&"hoso"ial8

+* Iss%es related to fa#il& stress, )eer relationshi)s, illness, or adoles"en"e #a& )resent asa"ade#i" diffi"%lt&*

=* Con$ersel&, beha$ior )roble#s at ho#e or at s"hool al'a&s sho%ld )ro#)t e$al%ation of

s"hool f%n"tioning*

• Ps&"hiatri" "o#orbidit& o""%rs "o##onl&8

+* /d<%st#ent disorders, #ood disorders, o))ositional defiant disorder, "ond%"t disorder, ti"

disorders, s%bstan"e ab%se, and other beha$ior )roble#s #a& )re"ede or follo' the

)resentation of learning )roble#s*

=* Less "o##onl&, )s&"hoti" disorders, )ersonalit& disorders, and obsessi$e-"o#)%lsi$e

disorder #a& %nderlie learning )roble#s*

Treatment

3ENER/L ME/SGRES

• 9or "hildren 'ith learning disorders, s)e"iali2ed ed%"ational a))roa"hes and t%toring are the

"enter)ie"es of treat#ent* This is often )ro$ided thro%gh Reso%r"e Roo# assistan"e or alternati$e

"lassroo# )la"e#ent*

• Children #a& also benefit fro# "lassroo# a""o##odations s%"h as )referential seating, etra ti#e for 

test ta0ing, %se of ele"troni" 'ord )ro"essors, and )ro$ision of 'ritten rather than $erbal instr%"tions*

•Children 'ith /D?D #a& also re1%ire beha$ioral thera)& and )har#a"ologi" thera)& to o)ti#i2e their)otential for learning*

• Treat#ent is #ost effe"ti$e 'hen it %ses a tea# a))roa"h, in"l%si$e of )arents, tea"hers, and other

thera)ists*

• 3rade retention, 'hi"h )ro$ides onl& a re)eat of the sa#e ed%"ational a))roa"hes that ha$e alread&

failed the "hild, 'ill not be hel)f%l*

Follow-up Recommendations

Children 'ith learning disabilities re1%ire "ontin%ed #onitoring of a"ade#i" )rogress* E$en 'hen the initial

learning )roble#s are resol$ed, later diffi"%lties #a& arise in 'riting, note ta0ing, "o#)osition, or organi2ation,

and 'ith #ore abstra"t a"ade#i" to)i"s*

Frequently Asked Questions

• H8 @hat is the e$iden"e that dietar& restri"tions 'ill hel) "ontrol h&)era"ti$it&

•  /8 Des)ite the #an& ane"dotal re)orts of $al%e, rando# "ontrolled st%dies ha$e not sho'n that

dietar& restri"tions ha$e $al%e 'hen the )atients are follo'ed for the long ter#*