Learning Disorder

Aka: Learning Disorder, Academic Skill Disorder, Learning Disability, Learning Difficulty, Academic Underachievement, School Problem Evaluation

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II. Definitions

  1. Learning Disability
    1. Discrepancy between IQ and achievement
    2. No obvious underlying neurologic Impairment or Intellectual Disability
    3. Specific learning disabilities include dyslexia, dysgraphia and dyscalculia
    4. Difficult to diagnose before second grade
  2. Academic Underachievement
    1. Unable to maintain average grades in classes and tests, performing below school grade level

III. Epidemiology

  1. Affects 2-12% of school population
    1. Special education received by 10-14%
    2. Specific Learning Disability in 4.6%
  2. Reading disorders are most common (8%)
  3. Boys affected 2-4 times more often than Girls

IV. Risk factors

  1. Medical History
    1. Prematurity
    2. Low birth weight
    3. Perinatal infections
    4. Prenatal exposure to drugs or Alcohol
    5. Postnatal lead exposure
    6. Early Speech Delay or Language Delay
    7. Traumatic Brain Injury
    8. Chronic medical conditions (e.g. Asthma)
  2. Family History
    1. Specific Learning Disability, special education or lower level of parental education
    2. Neurocutaneous disorders or other neurologic disorders
  3. Social History
    1. Family does not read for pleasure
    2. Domestic Violence or Substance Abuse in the home
    3. Poverty

V. Symptoms

  1. Delay in acquiring academic skills
  2. Dropping grades
  3. Excess time to complete work or learn new material
    1. Homework takes too long to complete
    2. Excess parental involvement
  4. Inconsistent performance
    1. Does better one-to-one
    2. Does better on homework than tests
  5. Behavior problems
    1. Disruptive behavior
    2. Homework refusal
    3. Class clown
    4. Hates school
    5. Frequent school absences
    6. Hides school work, lies about assignments

VI. Signs

  1. Subtle language difficulties
    1. Poor processing
    2. Poor phonological awareness
  2. Secondary inattention (up to 40%)
    1. Retention of information is poor
  3. Low self-esteem
  4. Depression
  5. Aggressive behaviors

VII. Differential Diagnosis

  1. Genetic Disorders
    1. Deletion at 22q11.2
    2. Klinefelter Syndrome
    3. Down Syndrome
    4. Fragile X
    5. Prader-Willi
    6. Angelman's Syndrome
    7. Rett Syndrome
    8. Neurocutaneous Disorders (e.g. Neurofibromatosis, Sturge-Weber Syndrome, Tuberous Sclerosis)
  2. Acquired Disorder
    1. History of prematurity
    2. Congenital Hydrocephalus
    3. Traumatic Brain Injury
    4. Prior cerebral infection (e.g. Encephalitis)
    5. Lead Poisoning or Mercury Poisoning
  3. Intellectual Disability (Mental Retardation) or Developmental Delay
  4. Autism Spectrum Disorder
  5. Attentional Disorders (e.g. Attention Deficit Disorder)
  6. Language or Developmental Disorder
  7. Emotional disorder
    1. Anxiety
    2. Depression
    3. Post-Traumatic Stress Disorder
    4. Psychosis
  8. Visual Impairment or Hearing Impairment
  9. Seizure Disorder
  10. Substance Abuse

VIII. Associated Conditions

  1. Mood and behavioral disorders
    1. Bullying
    2. Generalized Anxiety Disorder and other Anxiety Disorders
    3. Oppositional Defiant Disorder and other Behavioral Disorders
    4. Major Depression
  2. Other disorders impacting learning
    1. Attention Deficit Disorder
    2. Autism Spectrum Disorders and other neurodevelopmental disorders
    3. Speech Delay or Language Delay
    4. Social skill deficits
  3. Somatic Conditions
    1. Headaches
    2. Motor disorders

IX. Exam

  1. Growth Assessment
  2. Hearing Testing
  3. Visual Acuity testing
  4. Signs of other disease
    1. Cutaneous Signs of Dysraphism
    2. Dysmorphic features (e.g. Fetal Alcohol Syndrome)
    3. Chronic disease (e.g. Asthma, Seizure Disorder, recurrent Otitis Media)
    4. Neurocutaneous findings (e.g. Neurofibromatosis)

X. Diagnostics: As Indicated

  1. Intelligence Testing (IQ Testing)
  2. Mental Status Exam
  3. Developmental Evaluation
  4. Developmental Milestone
  5. Speech Exam
  6. Psychological Testing (examples)
    1. Draw a person
    2. Kinetic family drawing
    3. Sentence completion
    4. Thematic apperception test
    5. Cole's animal test

XI. Labs: As Indicated

  1. Lead Level
  2. Complete Blood Count
  3. Specific Indications
    1. Thyroid (TSH)
    2. Electroencephalogram

XII. Imaging: As Indicated

  1. Brain MRI
    1. Indicated for focal or progressive neurologic signs

XIII. Evaluation: School-Based

  1. Response to Intervention
    1. Early intervention initiated by school in response to Academic Underachievement
    2. Persistent lack of progress results in Individualized Education Program (IEP) Evaluation
  2. Individualized Education Program (IEP)
    1. Special Education Assessment to address student needs impacting academic performance
    2. Eligibility evaluation performed by multidisciplinary team
    3. Primary and secondary eligibility categories are identified
  3. Individualized Education Program Categories
    1. Medical Diagnosis and School Eligibility
      1. Cognitive Disability resulting in school academic performance
    2. Medical Diagnosis Only
      1. Correctable medical diagnosis (e.g. Visual Acuity) impacting learning
    3. School Eligibility Only
      1. Special Education Eligibility based on pure Learning Disorders (non-medical conditions)
  4. Alternative evaluations
    1. Nonschool psychology evaluations
      1. Often self-pay (not covered by insurance)
      2. Results often not accepted by the school to impact school interventions

XIV. Evaluation: Medical Provider

  1. History and exam as above
  2. Identify medical diagnoses impacting learning
  3. Medical provider may send a letter on patient behalf to school identifying medical findings andf request for school evaluation

XV. Prognosis

  1. Best outcomes for specific learning disabilities are when treatment is started by third grade

XVI. Resources: Learning Disability Screening

  1. Project Teach Rating Scales
    1. https://projectteachny.org/rating-scales/
  2. University of Washington Screening Tools
    1. https://depts.washington.edu/dbpeds/Screening%20Tools/ScreeningTools.html

XVII. Resources: Parents

  1. Child Mind Symptom Checker
    1. https://childmind.org/symptomchecker/
  2. Learning Disabilities Association of America
    1. https://ldaamerica.org/
  3. National Center of Learning Disabilities
    1. https://www.ncld.org/
  4. Response to Intervention Action Network
    1. http://www.rtinetwork.org/
  5. Understood
    1. https://www.understood.org/en

XVIII. References

  1. Bravender (2008) Clin Pediatr 47(6): 535-45 +PMID:18566352 [PubMed]
  2. Curtin (2019) Am Fam Physician 100(10): 628-35 [PubMed]

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