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.
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
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.
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.