Rudolph's Pediatrics, 22nd Ed.

CHAPTER 85. Learning Problems

Michael I. Reiff and Martin T. Stein

Estimates of the prevalence of learning disabilities range from 4% to 20%, depending on how they are defined.¹ Problems imposed by learning disabilities and different learning styles can significantly affect a child’s early sense of mastery and competence and can have lifelong implications on occupational functioning and psychological health. Learning disabilities cannot be diagnosed at an earlier age than the skills are expected to develop, but high-risk factors can be ascertained. Learning disabilities can be identified at any time throughout the school years. They may present with difficulty in individual subjects, underachievement, behavior problems, attention problems, and, eventually, school failure. If unrecognized, a chronic lack of school success can lead to low self-esteem, behavior problems, truancy, depression, high-risk behaviors of adolescence, and school dropout.

DEFINITIONS AND EPIDEMIOLOGY

LEARNING PREFERENCES AND STYLES

Learning preferences and learning styles refer to an individual’s preferred modes of and different approaches to learning based on their individual strengths and weaknesses. Although various learning styles exist, the most commonly referenced types are auditory, visual, and kinesthetic (learning by doing). Ideally, students learn effectively using a combination of these styles. Those who do not are at a strong disadvantage if their school teaches in a manner that does not match their individual learning style. The intent of identifying learning styles or preferences is to enable a student to intake and output information in ways that are most comfortable and successful.

UNDERACHIEVEMENT

Underachievement refers to lower academic performance than expected based on abilities (IQ). It is reflected by poor grades and school-work production. It may also be accompanied by lower than expected performance on tests of academic achievement. Possible causes of underachievement include attention deficit hyper-activity disorder (ADHD), learning style and other educational issues, emotional and behavioral disorders, family and social factors, and engagement in high-risk behaviors such as drugs and delinquency. Underachievement can lead to or reflect poor self-esteem. Unaddressed, this may lead to school failure and dropout.

LEARNING DISABILITIES

The most common definition of a learning disability is a significant to severe (1.5–2 standard deviation) discrepancy between a child’s abilities (as measured by an individually administered IQ test) and the child’s achievement (as measured by individually administered tests of achievement in reading, written expression, and mathematics).² This model is often used to determine who qualifies for services in schools, and in some school systems, a child needs a discrepancy of 2 standard deviations before qualifying for services. The problems with this model are that few characteristics differentiate poor readers with discrepancies from those without discrepancies.¹ In addition, the amount of discrepancy is not necessarily related to the severity of the learning disability³ and does not predict the reading level of a child over time in response to a reading intervention⁴ or how a child will respond to a given intervention.⁵Using a discrepancy model, children with low average IQs and commensurate low average achievement (both 1.5 to 2 standard deviations from the mean) would not qualify for services; and there is no evidence that they would not benefit from educational services similar to those with normal IQs.

The Individuals with Disabilities Educational Act (IDEA) defines a specific learning disability as a disorder in one or more of the basic psychological processes involved in understanding or in using language (spoken or written), which may manifest itself in an imperfect ability to listen, think, speak, read, write, spell, or to do mathematical calculations. This definition of learning disabilities includes such conditions as “perceptual handicaps, brain injury, minimal brain dysfunction, dyslexia, and developmental aphasia.”⁶ Federal regulations recognize learning disabilities in oral expression, listening comprehension, written expression, reading comprehension, mathematics calculation, and mathematics reasoning that are not caused by a sensory or motor handicap; mental retardation; emotional disturbance; or social, cultural, and economic factors.

The Diagnostic and Statistical Manual of Mental Disorders: DSM-IV-TR⁷ describes 4 categories of learning disabilities: reading disorder, mathematics disorder, disorder of written expression and learning disability not otherwise specified. According to the DS-MIV-TR, learning disorders are diagnosed when the individual’s achievement on individually administered, standardized tests in reading, mathematics, or written expression is substantially below expectation for age, appropriate educational experiences, and level of intelligence. The learning problems need to significantly interfere with academic achievement or activities of daily living that require reading, mathematical, or writing skills. If a sensory deficit (such as vision or hearing impairment) is present, the learning difficulties must be in excess of those usually associated with the deficit. Table 85-1 reviews a number of described learning disabilities.

Learning disorders may persist into adult life. In spite of these discrete definitions, there is a great deal of heterogeneity and overlap in learning disabilities. For example, there is little evidence for a learning disability in written expression in the absence of other learning disabilities. Coexisting conditions such as reading disability with attention deficit hyperactivity disorder is more impairing than reading disability in isolation.

Table 85-1. Definitions of Learning Disabilities

NONVERBAL LEARNING DISABILITIES

Nonverbal learning disorder (NLD) is characterized by a specific pattern of relative strengths and deficits in academic skills. Reading and spelling skills may be well developed in association with weaknesses in social areas. Children with NLD make more efficient use of verbal than nonverbal information in social situations and thus have difficulty reading social cues. In some cases, it may be difficult to differentiate NLD from Asperger disorder (see Chapter 92). In children under 4 years old who have NLD, psychosocial functioning can be relatively typical or involve only mild deficits. Following this period, children with NLD may develop externalizing behavior and may present with hyper-activity and inattention. They are frequently perceived as acting out and hyperactive and are commonly identified by their teachers as over-talkative, troublemakers, or behavior problems. With advancing years, activity level can normalize and even become hypoactive. By older childhood and early adolescence, the typical pattern of psychopathology is internalizing in nature, characterized by withdrawal, anxiety, depression, atypical behaviors, and social skills deficits. Their interactions with other children are stereotypical, and their facial expressions lack affect. This stereotypical behavior is often accompanied by deficits in social perception, judgment, and interaction skills. The neuropsychological assets and deficits that characterize NLD are evident in a wide variety of pediatric neurological diseases and disorders such as Asperger disorder, early shunted hydrocephalus, velocardiofacial syndrome, and Williams syndrome. Children with NLD are particularly prone to serious psychosocial dysfunction over the course of their development compared to children whose learning disabilities are a result of phonologic processing. NLDs are less prevalent than language-based learning disorders (0.1%–1.0% of the general population).^8,9

READING DISABILITY (DYSLEXIA)

NEUROBIOLOGY

Dyslexia is a neurobiologically based problem in reading in children and adults who otherwise have the intelligence and incentive necessary for accurate and fluent reading. It manifests with difficulties in word recognition and in poor spelling and word decoding (pronouncing nonsense words) abilities. Dyslexia is a persistent weakness in phonologic processing, the ability to analyze and synthesize phonemes (the smallest unit of recognized sounds). Dyslexia is persistent and does not represent simply a developmental lag in the ability to read.⁴ The estimated prevalence rates are 5% to 17.5% with an occurrence of 23% to 65% in children who have a parent with dyslexia. Replicated linkage studies suggest loci on chromosomes 2, 3, 6, 15, and 18.¹⁰

Speech is natural, but reading needs to be acquired and taught. To read, the beginner must be able to recognize that the letters and strings of letters represent the sounds of spoken language, that spoken words can be pulled apart into particles of speech (phonemes), and that the letters in a written word represent speech sounds. Deficits in phonologic awareness represent the most specific correlate of a reading disability.¹¹ If phonologic awareness is impaired, then readers cannot use their higher-order cognitive abilities, such as their intelligence and other language skills, to access the meaning until the words are decoded and identified. Phonologic difficulties are independent of intelligence.

Brain anatomy and imaging studies have been employed to investigate the development of neurophysiologic processes involved in reading.^12-14 These studies have shown differences in the temporoparietal-occipital brain regions between readers with dyslexia and nonimpaired readers. Functional magnetic resonance imaging studies of nonimpaired children demonstrate significantly greater brain activation in the left hemisphere (including the inferofrontal, superotemporal, parietotemporal, and middle temporal–middle occipital gyri) than is found in children with dyslexia. These studies demonstrate in children with dyslexia a failure of the left hemisphere posterior brain systems to function properly during reading as well as during nonreading visual-processing tasks.

The neurobiologic basis for dyslexia is a disruption of left hemisphere posterior brain systems while performing reading tasks. The evidence suggests that skilled readers use the left occipitotemporal word-identification area. The temporal lobes help distinguish sounds such as ba, ca, and da. Disruption of the posterior reading systems results in dyslexic children attempting to compensate by shifting to ancillary sites such as the Broca area inferior frontal gyrus (responsible for articulation and word analysis) and right hemisphere sites. These anterior sites are critical in articulation and thus may help children with dyslexia develop an awareness of sound structure through word formation, using lips, tongue, and vocal apparatus, and thereby enable the child to read, although more slowly and less efficiently than if the fast occipitotemporal word-identification system were functioning (Fig. 85-1). Functional imaging studies have also shown brain changes in a normalizing direction after the application of intensive phonological training of children with deficits in phonology.

Young adults with histories of childhood dyslexia may develop some accuracy in reading words; however, they remain slow readers. Others improve in accuracy, and as adults, they can be indistinguishable from nonimpaired readers on measures of reading comprehension. Persistently poor readers are more likely to have poorer cognitive/verbal abilities, attend more disadvantaged schools, and often have less linguistic stimulation at home.¹¹

CLINICAL PRESENTATION AND DIAGNOSIS

Risk factors for dyslexia in preschool children include a history of language delay, not attending to the sounds of words (such as trouble rhyming, confusing words that sound alike, mispronouncing words), difficulty learning to recognize letters of the alphabet, and a family history of dyslexia. A child with dyslexia in the early school years may have a history of delayed speech, not know letters by kindergarten, not begin to learn to read in first grade, and have difficulty sounding out words. Even after acquiring decoding skills (the ability to read single words in isolation), reading remains slow.¹⁵

Figure 85-1. Neural systems for reading. Three neural systems for reading are illustrated in this figure of the surface of the left hemisphere: an anterior system in the region of the inferior frontal gyrus (Broca area) believed to serve articulation and word analysis; 2 posterior systems, one in the parietotemporal region believed to serve word analysis, and a second in the occipitotemporal region (termed the “word-form” area) believed to serve for the rapid, automatic, fluent identification of words. (Source: From Shaywitz S. Overcoming Dyslexia: A New and Complete Science-Based Program for Reading Problems at Any Level. New York: Alfred Knopf; 2003:78. Used with permission.)

Children’s phonologic abilities can be assessed at about age 4 by tests evaluating the ability to focus on syllables and phonemes. Children with dyslexia lack phonemic awareness—the ability to focus on and manipulate phonemes, the speech sounds in spoken syllables and words. Typical phonemic awareness tests assess the ability to rhyme or figure out which word begins or ends with the same sound as another. Later on, children can be asked to pronounce words leaving out sounds (“say the word stop without the t sound: sop”) or count the number of sounds in a word (“dad, d/a/d: 3 sounds”). The ability to rapidly access names for numbers, objects, and letters at school entry is predictive of word reading, although it is less predictive later on. Children who have difficulty with both phonologic awareness and rapid naming are more impaired than are children with either deficit alone.¹⁵

Tests of reading measure decoding accuracy, fluency, and comprehension. Normed and validated measures include the Woodcock-Johnson III battery. Reading fluency can be assessed by such measures as the Gray Oral Reading Test, which measures fluency and pronunciation.¹⁶

Children with dyslexia have persistent problems through adolescence, and dyslexia does not remit spontaneously.⁴ Adolescents with dyslexia continue to have difficulty with phonologic processing measures. However, many dyslexic readers may become proficient in reading a circumscribed domain of words that recur over and over, and, thus can become fluent in reading in a special area of interest, or within a professional field. They may be accurate but still not fluent or automatic in reading unfamiliar words.¹⁵

MATH DISABILITY

Children with mathematics disability have a deficit in math fact retrieval. Accurate and fluent retrieval of single-digit arithmetic facts is felt to be important in freeing up higher cognitive processes for learning and applying more complex tasks. Children with both reading and math disabilities struggle even more with word-problem solving.¹ The risk of math disorder is increased 10 times in families where 1 child already has a math disorder. Genetic associations between math and reading disabilities are also high.

EVALUATION

Any brain injury that impairs cognitive functioning can result in learning disabilities. Medical history should include prenatal and perinatal events (prematurity, hypoxia, infections, drug exposure); head trauma or loss of consciousness; medications with central nervous system effects; and a family history of learning problems, learning disabilities, mental retardation, or developmental delays.¹⁷

During preschool pediatric visits, inquiries regarding reading difficulties in other family members should be obtained. A home history of risk for preschoolers includes limited exposure to language, conversation, and nursery rhymes and minimal exposure to books and reading. When these risk factors are ascertained, an early literacy intervention such as Reach Out and Read¹⁸ should be initiated.

If a child is just entering school, inquire about naming letters, counting objects, knowing some shapes and rhyme words. Information should also be gathered about any early speech and language difficulties, since children with these impairments are at high risk for reading disorders. In school-aged children, a history of grades in core subjects should be reviewed. Poor school performance may suggest a learning disability or behavioral condition that can mimic learning disabilities. Medical conditions associated with poor school performance are listed in Table 85-2. Table 85-3 suggests screening questions for learning disabilities that can be used in an office visit. The medical evaluation should include hearing and vision screening tests; an assessment for dysmorphic features and other physical anomalies; and a complete neurological examination including motor skills, coordination, and fine motor paper-and-pencil skills. Laboratory tests should be obtained only if suggested by history or physical examination. If a child has a learning disability, coexisting conditions should be considered. Approximately 60% of children with ADHD have school underachievement, and at least 12% have learning disabilities. Conversely, 10% to 30% of children with learning disabilities have ADHD (see Chapter 84). Children with learning disabilities have a higher prevalence of conduct disorder, speech and language disorders, depression, anxiety, and low self-esteem.¹

INTERVENTIONS

Interventions for learning disabilities that lead to strong outcomes include cognitive strategies, cognitive behavior approaches, and task analytic methods.

Table 85-2. Medical Associations with Poor School Performance or School Failure

*Often present with learning disorders.

INTERVENTIONS FOR DYSLEXIA

When a preschool child is discovered to have decreased exposure to oral language and minimal exposure to books and reading, the clinician should consider an early literacy intervention such as Reach Out and Read.^18,19 In this pediatric office–based program that promotes parents’ early literacy efforts with their children, developmentally and culturally appropriate books are available at health supervision visits for the child to take home. A new book is introduced at each health supervision visit from 6 months to 5 years old while the clinician observes and comments on the child’s interest; volunteer readers in the waiting room can complement the clinician’s efforts to encourage reading.

Developing the fundamental skills of phonologic processing and decoding is the primary treatment for dyslexia and is critical to help children avoid thinking of themselves as incompetent by improving their self-esteem. Intensive early intervention using evidence-based, phonologic-processing techniques can remediate or even prevent reading difficulties in primary school students. Classroom accommodations, such as extra time and attenuated assignments, may also be useful. There are no data to support treatments such as optometric training or other vision therapies, medications for vestibular dysfunction, chiropractic manipulation, or dietary changes.^2,11,15

Table 85-3. Screening Questions

Source: From Lindsay RI. School failure/disorders of learning. In: Bergman AB, ed. 20 Common Problems in Pediatrics. New York, NY: McGraw-Hill; 2001:328. Used with permission.

INTERVENTIONS FOR MATHEMATICS DISORDER

Effective interventions for mathematics disorder are not as well studied as those for dyslexia. Intervention programs have focused largely on mathematics fact retrieval and procedural skills and somewhat less on math-problem solving. Students benefit from clear conceptual explanations, pictorial representations of math problems, verbal rehearsal, timed practice, and reviewing material learned in the past. Students have made gains in math-problem solving through programs that teach them solutions to word problems and strategies to help them transfer these skills to more complex and novel word problems.¹

INDIVIDUALS WITH DISABILITIES EDUCATION ACT (IDEA)

In 1997, Congress passed the Individuals with Disabilities Education Act (IDEA). This law was updated in 2004.^20-23 The law states that appropriate public education should be available to all children with disabilities; all children with disabilities should have an individualized education program; their education should be in the “least restrictive environment”; public schools should provide special education for children enrolled in private schools; and teachers should be adequately trained. The IDEA mandates special services for children whose disabilities severely affect their educational performance. Specific learning disabilities recognized by the IDEA include disabilities of oral expression, listening comprehension, written expression, basic reading skills, reading comprehension, mathematics calculation, and mathematics reasoning. Parents or a school can initiate a request for testing for an individualized education plan.

Before 2004, a child was not offered services unless a discrepancy was documented between abilities (IQ) and achievement in one or more areas of learning: oral expression, listening comprehension, written expression, basic reading skill, reading comprehension, mathematics calculation, and/or mathematics reasoning. This meant, however, that students would have to fail for long periods of time before they showed sufficiently large deficits in academic achievement to satisfy the “severe discrepancy” requirement and begin receiving special education services. This discrepancy requirement was particularly problematic for students living in poverty, students of culturally different backgrounds, and those whose native language was not English. It is now equally acceptable to have students who show signs of learning difficulty to be provided with a series of increasingly intensive instructional or behavioral interventions before an individualized education plan is written. This can include systematic instruction in phonemic awareness, phonics, vocabulary development, reading fluency including oral reading skills, and reading comprehension strategies. In this manner, students can begin to receive interventions early instead of waiting until they fail (as in the discrepancy model). If they do not show improvement by responding to these interventions, then a formal individualized education plan can be written for 1 or more of the specific learning disabilities. Ongoing advocacy for children with learning problems and disabilities remains critical.^6,23-25

PROGNOSIS

Even when treated, children with reading disabilities remain poorer readers than their peers, even though reading scores improve over time. High school and college students with a history of dyslexia are often similar to classmates with regard to word recognition and comprehension, but they continue to struggle with less automatic, slower reading that requires more effort. They can read accurately, but not fluently, and often need extra time. Higher-order language and cognitive skills are intact. With optimal accommodations, they can do quite well academically and even enter rigorous postgraduate programs and professional schools, even though they may need support services. Without intervention, individuals with learning disabilities and language impairment (see Chapter 86) may be at greater risk for substance abuse in adolescence, poorer social and behavioral outcomes, school failure and dropout, and poorer occupational and socioeconomic status.