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Pediatric Update


Pediatric Update

Fall 2006

Physician Scrutiny Helps in Identifying Learning Disabilities

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Children struggling in school should be evaluated for learning disabilities.

Pediatricians working closely with parents of children who have difficulty learning in the classroom can make a significant difference in the child’s long-term educational trajectory. “Children who are having difficulties in school, whether it’s with an academic subject or with processing and understanding new information, need to have an evaluation,” says Esther Sinclair, Ph.D., a UCLA educational psychologist.

In many cases, these difficulties are the result of learning disabilities, which, according to UCLA clinical psychologist Martha Jura, Ph.D., generally are defined in terms of “unexpected underachievement”—that is, it is not explained by intellectual level, inadquate schooling, or emotional status.

Diagnosing the problem is only the first step. The next task is to develop specific school interventions. The federal Individuals with Disabilities Education Act (IDEA) defines a variety of disabilities, including learning disabilities, that school systems must address by providing special services under certain circumstances, and requires, in the most general sense, that children with disabilities be given access to a free and appropriate public education.

In many cases, learning disabilities defined under IDEA in terms of a discrepancy between ability and achievement overlap with learning disorders as defined in the Diagnostic and Statistical Manual of Mental Disorders. In some instances, though, “a learning disorder diagnosed in hospitals and clinics is not always defined as a disability by the educational system,” notes Dr. Jura. Both describe a significant discrepancy between expectation and achievement. However, a learning disability commonly requires specification of the underlying processing problems, while a learning disorder does not. Both definitions have exclusionary criteria, indicating that the discrepancy or shortfall is not accounted for by one of several problematic conditions such as sensory impairment or mental retardation, or environmental or cultural disadvantage.

Federal procedures around learning disabilities are subject to change, driven in part by economic and practical realities—many public school systems lack the resources to provide adequate special education services to every child with a learning problem. However, the reauthorization of IDEA in 2004 changed procedures governing the identification of specific learning disabilities and eligibility decisions around special educational services in response to educational research. The law now permits school systems to use a “new” response-to-intervention model or the “old” discrepancy model(the plan used by schools for years), “signaling the hope that schools can shift from a ‘wait-to-fail’ approach to a more preventative and early intervention approach,” Dr. Jura says. Schools in California and around the nation are struggling to bring their guidelines into compliance with the new law. “This is all in flux, which makes it difficult for pediatricians to know how best to advocate for their patients,” Dr. Jura notes.

The first step a pediatrician should take when a patient is identified with learning issues is to urge parents to discuss concerns with the child’s teacher, who can offer less formal interventions. If necessary, the family can seek a formal evaluation from the home school to determine whether the child qualifies for special education. If the child is eligible, parents, teachers and school system representatives establish an Individualized Education Program (IEP) to ensure appropriately specialized services.

Parents should be encouraged to learn what constitutes an adequate learning evaluation, Dr. Jura says. Since the goal of most assessments is to obtain services for children who need them, this can depend on the definition of learning disability being used. In the old discrepancy model, the evaluation focuses on intellectual, cognitive and achievement testing to establish a discrepancy between ability and achievement, and, commonly, the underlying processing problems. In the new response-to-intervention model, the inquiries and testing will be much more specific, involving, for example, curriculum-relevant measurements. Assessments and increasingly intensive interventions, starting in class and in small groups, will precede any IEP evaluation. In either case, Dr. Jura notes that beyond simply ruling out any conditions that might preclude children from receiving services, any comprehensive evaluation should look at anxiety, depression and attention, or any other factor that might negatively affect learning. It is important to keep the big picture in mind, she says; the focus of any assessment should be on the child and not criteria. “Whatever the school’s perception and rules, the parents have their own point of view. If they see that something is wrong, all they want is for it to be understood and fixed. Ideally, a good evaluation is a road map for doing this,” she says.

Whatever model or plan the school uses, parents always have the option of requesting an IEP evaluation if they are concerned about their child’s schooling. Just because an evaluation is scheduled doesn’t mean the family’s problems are over, Dr. Sinclair notes. It often is up to the discretion of the district team to decide which students are learning disabled and in need of services. “It is naïve to assume that every child with problems is going to get special help at school,” says Dr. Sinclair. “Schools follow a narrow definition of learning disability so that only those with the greatest need get attention. If a child doesn’t meet the district’s criteria for special education, there tends to be limited discussion about other avenues for help. Yet, the parent knows something still is not right.” In such cases, parents can seek evaluations and recommendations through professionals in the community, though these may be expensive.

Most commonly, teachers have referred children for evaluation sometime during the third grade, at which time the emphasis in school shifts from acquiring skills to learning information. "Because schools have limited resources, it has been almost impossible for a young child [with a learning problem] in first or second grade to get identified,” Dr. Sinclair says. “But the sooner a problem is addressed, the more likely it is to be overcome.”

Educators hope that shifts in identifying and dealing with students with learning problems will facilitate exactly this process. At this point, however, nothing is certain, and pediatricians should not wait for parents to bring up their child’s learning problem during office visits. “Pediatricians may need to do some probing to find out how things are going in school,” Dr. Jura says, and perhaps might ask specifically about reading because of its importance in school and life, and about problems with attention, which can negatively affect both academic achievement and social behavior. If both the parent and pediatrician are concerned, then the parent should be encouraged to talk with the teacher and school psychologist about options for addressing the student’s needs. Over time, the pediatrician and parent can work together to figure out how to pursue solutions in the school and/or the community.

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