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BHIPP Bulletin

Learning Disorders and Intellectual Disability
Volume 2, Issue 5
November, 2016

 

INTRODUCTION

A common presenting concern in pediatric primary care offices is poor academic performance. There are several reasons why a child may not be performing at their expected level. In this 4th article in our school series, we will discuss two of these: Learning disorders (LD) and intellectual disability (ID).

Children with either a learning disorder or intellectual disability may try very hard in school, follow instructions, etc. but continue to underperform or fall behind. If not addressed, this can lead to frustration and poor self-esteem. Additionally, children with ID or LD may become anxious, withdrawn, depressed or act out. Since these children are at increased risk for co-morbid psychiatric disorders, such as ADHD, anxiety and depression it is important to screen for these associated conditions.

Pediatric primary care providers may participate in the comprehensive care of children with LD and ID. Although PCPs should not diagnose these conditions, they can inquire about the child’s educational progress and look for early signs of LD/ID (see Box 1). When a child has a suspected LD or ID the PCP should first asses the child for medical problems that may be interfering with the child’s ability to learn (i.e. ADHD, genetic syndromes, etc.). Then, the provider may refer for further evaluation if deemed appropriate (see below) and assist the family in coordination of care.

Box 1. Signals that a Child May Have a Learning Disorder or Intellectual Disability

  • Difficulty understanding and following instructions

  • Trouble remembering what someone just told him or her

  • Fails to master reading, spelling, writing, and/or math skills, and thus fails 

  • Difficulty distinguishing right from left; difficulty identifying words or a tendency to reverse letters, words, or numbers; (for example, confusing 25 with 52, "b" with "d," or "on" with "no")

  • Lacks coordination in walking, sports, or small activities such as holding a pencil or tying a shoelace

  • Easily loses or misplaces homework, schoolbooks, or other items

  • Difficulty understanding the concept of time; is confused by "yesterday, today, tomorrow"

    Source: AACAP Facts for Families.

EDUCATIONAL APPROACH

The Individuals with Disabilities Education Act (Public Law 108-446; IDEA), Section 504 of the Rehabilitation Act, and the Americans with Disabilities Act define the rights of students with ID and LD. This allows parents to request a formal educational evaluation by the school district to determine eligibility for school services. These services may include special education, speech therapy, etc. as described in our October newsletter. Early identification and engagement in these services will optimize that outcome for children with both LD and ID.


LEARNING DISORDERS

An estimated 2.6 million children aged 6-11 years old are affected by a learning disability. Learning disabilities may cause a child to have difficulty learning to listen, read, spell, write, solve mathematical problems and organize information. Learning disorders frequently run in families and are highly associated with ADHD. Although all learning disorders are now grouped together in the DSM-5 as “Specific Learning Disorder,” these may include:

     Dyslexia: Difficulty reading, spelling and recalling known words.
     Dyscalculia: Difficulty solving math problems and understanding mathematical concepts,
      sequencing information or events.
     Nonverbal learning disability: Difficulty with non-verbal cues, such as body language.
     Dysgraphia: Difficulty with handwriting, spelling, and thinking and writing simultaneously.

Furthermore, LD should be in the differential diagnose with evaluating a child for attentional difficulties and poor school performance. Children with learning disorders often appear distracted, inattentive or off-task as they are not able to follow the teacher and/or assignment due to their LD.


INTELLECTUAL DISABILITY

Intellectual disability is characterized by significant impairments in both intellectual functioning (IQ) as well as adaptive behavior, which includes the ability to perform many everyday social and practical skills. When looking at IQ scores, a score more than 2 standard deviations below the mean may represent ID (below 70). Children with IQ scores ranging from 70-85 may be characterized as having borderline intellectual functioning.

The age of identification can vary and is usually dependent upon the severity of the impairment. For example, severely affected children are typically identified earlier because they fail to meet expected milestones in the first 2 years of life. Gross motor development is often within the normal range in children with ID; however, receptive language delay is almost always present. Some children with ID will be identified due to associated medical conditions, i.e. genetic syndromes.

The cause of ID is not always ascertained, but it is important to make an attempt to identify the cause. There are certain conditions, i.e. inborn errors of metabolism, may be treated early on if identified. Prenatal and genetic causes are the most common etiologies of ID. Fragile X and Down’s Syndrome are common genetic causes of ID and Fetal Alcohol Spectrum Disorder (FASD) is the most common prenatal cause of ID. Careful physical examination, including a neurological examination, may reveal abnormal findings which may also give a clue to the underlying etiology. If a genetic syndrome is suspected, consultation and/or referral to a geneticist is often recommended.

Additional Resources on Learning Disorders and Intellectual Disability
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Meet the BHIPP Team
Dr. Nicole Gloff is a clinical consultant with the BHIPP team and has worked with the program since 2014. She is an Assistant Professor of Child and Adolescent Psychiatry at the University of Maryland School of Medicine. Dr. Gloff received her B.A. in Chemistry from St. Mary’s College of Maryland. She then earned her medical degree at the University of Maryland School of Medicine. Dr. Gloff completed her general psychiatry residency training at the University of Maryland/Sheppard Pratt. Following residency, she completed a child and adolescent psychiatry fellowship at the University of Maryland where she served as Administrative Chief Resident.

Upcoming Events

Linking Mental Health to Academic Success: Partnering for Wellness
Eastern Shore School Mental Health Coalition 6th Annual Conference
CME Event
Friday, November 18, 2016

8:30 am - 4:00 pm 
Salisbury Unversity, Guerrieri University Center

Dr. Nicole Gloff will present the keynote address, "When is it More Than Just a Worry? Identifying and Helping Children with Anxiety."

Sponsored by:
The Eastern Shore School Mental Health Coalition (ESSMHC)
and Salisbury University

BHIPP Bulletin Newsletter Archive

October 2016: Educational Services: Know Your Rights and Resources
September 2016:
Goodbye Summer, Hello School (Refusal)
August 2016: College Students and ADHD
July 2016: It's Summertime! ADHD and "Drug Holidays"
June 2016: Understanding Vyvanse
May 2016: Children's Mental Health Awareness Week, May 1-7, 2016
April 2016: "Universal" approaches for child mental health problems
March 2016: Pharmacological interventions for sleep concerns
February 2016: Behavioral interventions for sleep concerns
January 2016: Assessment of sleep disorders
November 2015: 5S's: Key questions for consultation
October 2015: Case discussion regarding school refusal
Copyright © 2016 Maryland Behavioral Health Integration in Pediatric Primary Care (BHIPP), All rights reserved.


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