Learning Disabilities: How Pediatricians Can Help

Approximately 10 percent of U.S. children have a learning disability, according to a review of data from the National Survey of Children’s Health. Despite this high prevalence, learning disabilities are often unaddressed, underaddressed or incorrectly addressed by families and schools.

“Pediatricians are well positioned to counteract those issues,” says Elaine E. Schulte, MD, MPH, Chair of the Department of General Pediatrics at Cleveland Clinic.

In a recent article in a supplement to Cleveland Clinic Journal of Medicine, Dr. Schulte elaborated on primary care pediatricians’ roles in assessing learning disability, initiating school services and otherwise supporting children and their families.

How to assess learning disability

The Individuals with Disabilities Education Act (IDEA), which governs considerations schools must make for learning-disabled students, broadly defines learning disability as impairment in one or more of the following:

• Math
• Understanding or using written or spoken language
• Information processing
• Memory
• Reading (including dyslexia and hyperlexia disorder)

The IDEA also includes perceptual disabilities, brain injury, minimal brain dysfunction and developmental aphasia as learning disabilities.

Assessing these conditions can involve any of the following:

Thorough medical evaluation to rule out underlying or associated medical issues. “Fetal alcohol syndrome, dysmorphisms, other syndromes and apparent genetic causes should be ruled out,” says Dr. Schulte. Patients should have vision and hearing screenings to detect potential sensory impairments that may resemble features of a learning disability. Medication side effects or, in older children, substance abuse also can mimic learning difficulties.

Identifying risk factors. Look for risk factors such as:

• Prematurity
• Low birth weight
• Early-life malnutrition
• Poverty
• Understimulating environments
• Head injury
• Epilepsy and other chronic health conditions
• Family history of learning disabilities, attention deficit, memory difficulty or dropping out of school

Watching for early warning signs. Indicators of learning disability can include:

• Speech delay
• Problems discriminating sounds
• Difficulty learning letters and sounds
• Difficulty following directions or responding to questions
• Impaired fine motor skills, such as holding utensils, buttoning clothing and using crayons
• Impaired visual-spatial processing, such as difficulty matching shapes or inability to copy information from a whiteboard to paper

Detecting limitations in executive function. The prefrontal cortex does not start to fully develop until a child is 7 to 8 years old, notes Dr. Schulte. 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 or difficulty with perceptual reasoning. Nonverbal learning disabilities also are often seen in those with fetal alcohol syndrome or other fetal alcohol spectrum disorders.

Psychological evaluation for attention deficit hyperactivity disorder (ADHD). “Children with ADHD are twice as likely to have dyslexia, and, conversely, children with dyslexia are twice as likely to have ADHD,” says Dr. Schulte. “It is difficult to establish which condition is primary. Psychological assessments should be performed in a timely fashion to delineate the cause.”

How to initiate school services

School districts’ assessments vary, but they are required to evaluate all areas of suspected learning disability. 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.

If a child’s learning disability affects his or her effective educational progress, the school must develop an individualized education plan (IEP) — a written contract outlining specific goals and measurable outcomes. It may include school placement determination and specific services like occupational therapy, physical therapy, and speech or special education services.

If a disability is determined not to be a cause of educational impairment, the child will not qualify for an IEP but may be eligible for a 504 plan, which typically involves making accommodations such as classroom seating location and testing modifications.

Pediatricians can play a key role in requesting the initial multifactorial learning disability assessment on behalf of the family, notes Dr. Schulte. A letter outlining the suspected learning disability should be addressed to the school principal. This information can help the school formulate an IEP or 504 plan later.

“Talk to parents about the need for additional, independent testing and be prepared to refer them to appropriate sources as well as to neuropsychological resources, when warranted,” says Dr. Schulte.

Before an IEP or 504 plan is established, pediatricians also can communicate with teachers about recommended classroom strategies, such as moving the child toward the front of the class.

Pediatricians’ most delicate role

Apart from assessing learning disability and initiating school services, pediatricians’ most delicate role may be supporting children and their families throughout the process, notes Dr. Schulte.

“The primary care pediatrician should emphasize to the child that everyone learns differently and in a way best suited to him or her,” she says. “The child should know that everyone’s brain works 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 at sports or the arts.

“Parents and guardians need to know that learning disability is not the result of poor parenting,” says Dr. Schulte. “Moreover, the pediatrician should emphasize that the child is not lazy or stupid, and that the condition can be frustrating for the child. Patience, rather than force, is to be encouraged.”