Learning Problems

Learning Problems: Excerpt from The 5-Minute Pediatric Consult

Chloe Brittan, MDPaul P. Wang, MD (4th Edition)

Learning Problems - BASICS

Learning Problems - description

• Learning disorders, or learning disabilities, are defined in the Diagnostic and Statistical Manual of Mental Disorders, 4th edition (DSM-IV) as academic achievement that is substantially below the level expected for age, schooling, and general intellectual ability, and that cannot be accounted for by psychosocial factors.
  • In British medical literature, “learning disability” is often synonymous with “mental retardation.”
• Learning disability may affect reading, writing, spelling, or math.
• Any given child may have more than 1 learning disability.
• Learning disabilities have neurobiologic and genetic roots.
• Reading disorder, which is also known as dyslexia and is the most frequently diagnosed type of learning disorder, is characterized by impairments in phonologic processing.

Learning Problems - epidemiology

Psychiatric comorbidity is frequent, either as a complication of learning problems or as an etiologic factor in their development.

Learning Problems - incidence

Estimated incidence ≥10% in school-aged children:

• Typically not evident until academic demands are placed on affected children.

Learning Problems - etiology

Speculative etiologies (widely discussed but essentially unproven):

• Food allergies
• “Developmental optometric” disorders
• Exposure to food preservatives or sugar

Learning Problems - DIAGNOSIS

• General goal is to determine whether the learning problems result from a primary medical or psychosocial condition. If no such condition is identified, then the patient may have a specific learning disability.
• The pediatrician also is in a good position to identify social and environmental factors that may be associated with learning problems, and can coordinate the appropriate medical, psychiatric, and/or psychoeducational evaluation, with consultation as indicated.
• Early identification of learning problems and appropriate intervention help to prevent the cascade of negative consequences triggered by poor academic achievement:
  • Phase 1a:
    • 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 1b:
    • 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 2:
    • For patients with learning problems that are suspected to be primary (i.e., specific learning disabilities), a complete psychoeducational evaluation is indicated.
    • If ADHD present, treatment may be directed by the primary care physician or by a subspecialist.

Learning Problems - signs & symptoms

Learning Problems - history

• Ask when and how the child fails in his or her daily academic pursuits:
  • For specific learning disabilities, problems may occur in only one class.
  • For attention deficit, problems may be broad based and may emerge as children move into more formal didactic settings.
  • With borderline mental retardation or other chronic problems, there may be a long history of developmental concerns.
• If decline in school performance is recent or new, consider new pathophysiologic processes, such as psychosocial issues, new vision or hearing impairment, side effect from new medication, or neurodegenerative disorder (rare).
• Poor school performance commonly leads to depression, poor self-esteem, and possible behavior problems.
• Past medical history, medications, review of systems, psychosocial stresses:
  • Identify factors that may affect learning.
  • Early language delays are common among children with learning disorders.
• Family history may be positive for learning or attention problems that are similar to the child’s.

Learning Problems - physical exam

• Subtle dysmorphology: May suggest the presence of a genetic syndrome or a pattern of malformation resulting from teratogenic fetal exposures (e.g., alcohol, phenytoin)
• Abnormal neurologic examination:
  • Any focal signs demand additional evaluation.
  • Soft signs (neuromaturational signs) are often present in children with learning problems, but are nonspecific.
• Abnormal audiology or vision screening: Vision or hearing problems may be direct cause of learning problem.

Learning Problems - tests

Behavioral screening should be performed, but no laboratory studies are routinely indicated. The history and physical examination may provide specific indications for further testing.

• Standardized behavior questionnaires:
  • Diagnosis of ADD is critically dependent on input from teachers and parents.
  • Psychiatric complications, such as depression, should also be considered.
• Lead level, thyroid functions, karyotype, HIV testing, hearing and vision testing, EEG, neuroimaging: Each of these can be considered if the history or physical exam provide specific indications.
• Psychoeducational evaluation:
  • Comprehensive evaluation serves as the cornerstone of diagnosis and educational intervention.
  • Testing must be performed individually and should include general intelligence and academic achievement testing.
  • Federal law requires schools to provide comprehensive evaluations on written request by the parents to the school principal. Specific information for each state can be obtained from the National Dissemination Center for Children with Disabilities (800-695-0285; www.nichcy.org).
  • Many centers outside the school system (e.g., hospital-based centers) also conduct evaluations of children with learning problems.
• Neuropsychologic evaluation: For children who do not respond to first-line educational interventions, more extensive neuropsychologic testing may elucidate specific cognitive strengths and weaknesses that may help in developing an effective educational plan.

Issues for referral:

• Referrals to medical and psychologic professionals may be helpful for both diagnostic and therapeutic purposes.
• When a specific medical etiology is suspected, the choice of subspecialist for referral will be clear.
• When no specific etiology is apparent, consider referral to a clinician experienced with learning disabilities, who may assist in comprehensive diagnostic formulation, pharmacologic treatment when indicated, developmental follow-up, and advocacy.

Clinical pearls:

• Comorbidity and symptomatic overlap are common among ADHD, specific learning disabilities, and other psychiatric disorders:
  • Students who have a learning disability or are depressed may show symptoms of inattention.
  • Academic or attention difficulties may lead to spiraling psychologic problems, from depression or damaged self-esteem to conduct disorder and school dropout.
• Normal attention and activity in the physician’s office do not rule out ADHD:
  • Many children with ADHD show significant difficulties with inattention and distractibility, but little hyperactivity.
  • Even children with severe ADHD may appear attentive in the intimidating and artificial milieu of the doctor’s office or when engaged in highly motivating and highly reinforcing computer games.

Learning Problems - differencial diagnosis

Children’s school problems may result from a specific learning disorder or may be the secondary effect of some other medical or psychosocial problem.

• ADHD may present as a learning problem, especially when the inattentive and distractible symptoms of the diagnosis are greater than the hyperactive symptoms.
  • May be difficult to distinguish from a learning disorder, and the 2 also may be found comorbidly
  • Careful psychoeducational assessment may be needed to clarify these diagnoses.
• Sensory impairments:
  • Hearing or vision impairments may cause learning problems.
  • School screening results should be confirmed in children with learning problems.
• Neurologic:
  • Absence seizures and other nonconvulsive epileptic disorders are much less common than ADHD but may mimic its symptoms.
  • Narcolepsy also is associated with learning problems.
  • Neurodegenerative disorders such as Niemann-Pick disease, adrenoleukodystrophy, ceroid lipofuscinosis, and subacute sclerosing panencephalitis may rarely present as school-age learning problems.
• Mental retardation: In some cases, borderline and mild mental retardation are not recognized until school entrance.
• Genetics: Some genetic syndromes may show subtle dysmorphology that is not noted until learning problems arise. Examples include:
  • Sex chromosome aneuploidies
  • Fragile X syndrome in both boys and girls
  • Neurofibromatosis
  • Tuberous sclerosis
  • Velocardiofacial/DiGeorge syndrome
• Nutritional, toxicologic, infections: Lead intoxication, chronic malnutrition, iron deficiency, hypothyroidism, and HIV infection may have insidious effects on cognitive function.
• Iatrogenic interventions: Medical therapies may compromise learning abilities; an example is treatment with antiepileptic drugs and other medications that affect cognition.
• Psychosocial:
  • Issues related to family stress, peer relationships, illness, or adolescence may present as academic difficulty.
  • Conversely, behavior problems at home or at school always should prompt evaluation of school functioning.
• Psychiatric comorbidity occurs commonly:
  • Adjustment disorders, mood disorders, oppositional defiant disorder, conduct disorder, tic disorders, substance abuse, and other behavior problems may precede or follow the presentation of learning problems.
  • Less commonly, psychotic disorders, personality disorders, and obsessive-compulsive disorder may underlie learning problems.

Learning Problems - TREATMENT

Learning Problems - general measures

• For children with learning disorders, specialized educational approaches and tutoring are the centerpieces of treatment. This is often provided through Resource Room assistance or alternative classroom placement.
• Children may also benefit from classroom accommodations such as preferential seating, extra time for test taking, use of electronic word processors, and provision of written rather than verbal instructions.
• Children with ADHD may also require behavioral therapy and pharmacologic therapy to optimize their potential for learning.
• Treatment is most effective when it uses a team approach, inclusive of parents, teachers, and other therapists.
• Grade retention, which provides only a repeat of the same educational approaches that have already failed the child, will not be helpful.

Learning Problems - FOLLOW UP

Children with learning disabilities require continued monitoring of academic progress. Even when the initial learning problems are resolved, later difficulties may arise in writing, note taking, composition, or organization, and with more abstract academic topics.

Learning Problems - bibliography

1. Buttross S. Attention deficit-hyperactivity disorder and its deceivers. Curr Probl Pediatr. 2000;30:37–50.
2. Eden GF, Moats L. The role of neuroscience in the remediation of students with dyslexia. Nat Neurosci. 2002;5(suppl):1080–1084.
3. Grigorenko EL. Developmental dyslexia: An update on genes, brains, and environments. J Child Psychol Psychiat Allied Discipl. 2001;42:91–125.
4. Hechtman L. Assessment and diagnosis of attention-deficit/hyperactivity disorder. Child Adolesc Psychiatr Clin North Am. 2000;9:481–498.
5. Levy SE. Pediatric evaluation of the child with developmental delay. Child Adolesc Psychiatr Clin North Am. 1996;5:809–826.
6. Mannuzza S, Klein RG. Long-term prognosis in attention-deficit/hyperactivity disorder. Child Adolesc Psychiatr Clin North Am. 2000;9:711–726.
7. Mazzocco MM. Advances in research on the fragile X syndrome. Mental Retard Dev Disabil Res Rev. 2000;6:96–106.
8. O’Brien G. Adult outcome of childhood learning disability. Dev Med Child Neurol. 2001;43:634–638.
9. Reiff MI. Adolescent school failure: Failure to thrive in adolescence. Pediatr Rev. 1998;19:199–207.
10. Schonwald A, Lechner E. Attention deficit/hyperactivity disorder: Complexities and controversies. Curr Opin Pediatr. 2006;18(2):189–195.

Learning Problems - CODES

Learning Problems - icd9

• 314.0 Attention deficit disorder
• 314.01 With hyperactivity
• 315.02 Developmental dyslexia
• V40.0 Problems with learning
• 315.0–315.9 Developmental learning delays

Learning Problems - FAQ

• Q: What is the evidence that dietary restrictions will help control hyperactivity?
• A: Despite the many anecdotal reports of value, random controlled studies have not shown that dietary restrictions have value when the patients are followed for the long term.

Book Source Details

• Book Title: The 5-Minute Pediatric Consult
• Author(s): M. William Schwartz MD; et al.
• Year of Publication: 2008
• Copyright Details: The 5-Minute Pediatric Consult, Copyright © 2008 Lippincott Williams & Wilkins.

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Copyright notice for book excerpts: Copyright © 2008 Lippincott Williams & Wilkins. All rights reserved.

More About This Book: Title: The 5-Minute Pediatric Consult Authors: M. William Schwartz MD; et al. Publisher: Lippincott Williams & Wilkins Copyright: 2008 ISBN: 0-7817-7577-9

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