5/23/2017 Specific learning disabilities in children: Role of the primary care provider ­ UpToDate

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Specific learning disabilities in children: Role of the primary care provider

Author: L Erik von Hahn, MD Section Editors: Carolyn Bridgemohan, MD, Marc C Patterson, MD, FRACP Deputy Editor: Mary M Torchia, MD

All topics are updated as new evidence becomes available and our peer review process is complete. Literature review current through: Apr 2017. | This topic last updated: Apr 28, 2017.

INTRODUCTION — Routine supervision of a child's educational status, including advocacy to assure the child's access to quality educational practices, is an important component of health supervision [1]. Educational status has significant effects on long­term health [2]. Factors that are associated with positive health outcomes include attending a high­quality preschool, social­emotional status in elementary school, and completion of high school [3]. Early intervention programs, offered before the age of five years, appear to be particularly important predictors of future health status [4]. For these reasons, routine supervision of a child's education is an important component of well­child care.

The role of the primary care provider in the evaluation and management of learning disabilities (LD) in children will be discussed here. The clinical features, evaluation, and management of LD in the educational system and laws pertaining to specific learning disabilities in the United States, are discussed separately. (See "Specific learning disabilities in children: Clinical features" and "Specific learning disabilities in children: Evaluation" and "Specific learning disabilities in children: Educational management" and "Definitions of specific learning disability and laws pertaining to learning disabilities in the United States".)

OVERVIEW — The evaluation and management of learning disabilities (LD) is a primary responsibility of the school system, but it requires input from multiple professionals, including the primary care provider. The primary responsibilities of the primary care provider are to assist in the identification of LD, assure management of LD, address co­occurring conditions, and to provide case management under a medical home model [1]. (See 'Early identification' below and "Children with special health care needs", section on 'Medical home'.)

Secondary roles include serving as a resource to families about community services, advocating for the child's rights and needs at school, serving as a mediator between the family and the school team, and serving as a consultant and resource to the school team. (See 'Resources' below and 'Advocacy and support' below and 'Mediator' below.)

● Primary roles – The diagnosis of LD using psychometric tests usually is made by educators and/or psychologists. Nonetheless, the primary care provider's expertise and unique clinical perspective play a vital role in the identification and evaluation of children with LD. A primary role of the pediatric clinician is to help identify the student who may have LD and/or who may need to be evaluated for LD. In addition, the pediatric clinician completes a medical evaluation for co­occurring conditions such as attention deficit hyperactivity disorder, sleep problems, and seizures, among others. Once identified, the primary care provider should discuss reasons for learning failure with the family and provide information about LD and its co­occurring conditions. (See 'Early identification' below and 'Education and counseling' below.)

Primary care providers who have a longstanding relationship with the child and family may be better able to help the family articulate their concerns than educators or clinicians with whom the family is less familiar, thus helping to identify students who may have LD and have not yet been identified by the child's teacher or https://www.uptodate.com/contents/specific­learning­disabilities­in­children­role­of­the­primary­care­provider/print 1/34 5/23/2017 Specific learning disabilities in children: Role of the primary care provider ­ UpToDate school team. Primary care providers also may have information that can facilitate the school team's understanding of the child's learning needs (eg, knowledge of psychosocial, cultural, medical, or environmental factors that affect the child's ability to learn), thereby reinforcing the need for formal evaluation [5]. In addition, the primary care provider can assist the parents with the interpretation of school evaluations and in negotiating the special education system once formal evaluations are completed [6]. (See 'Advocacy and support' below.)

Finally, the pediatric clinician can help the family understand LD and its co­occurring conditions so that they can seek appropriate services. (See 'Care coordination' below.)

● Secondary roles – The primary care provider can also play a number of secondary roles in the management of children with disabilities who receive special services at school. These include providing information about and/or referrals to community agencies that provide treatment for the disability and its co­occurring conditions; serving as an advocate for the child vis­à­vis the school and other community agencies; serving as a mediator between the family and the school team when there are disagreements; and assisting the school team in the delivery of services. (See 'Communicating with the school team' below and 'Mediator' below.)

EARLY IDENTIFICATION — Early identification of learning disabilities (LD) is crucial to providing appropriate interventions [7,8]. Because early recognition may affect ultimate outcome, pediatric health care providers should have a low threshold for considering LD in children who are at risk for LD and children who have problems at school (whether the problems are in academic achievement, behavior, attention, or social interaction). The primary care provider can play a critical role when the child's learning problems are overlooked by the family and/or school personnel. LD should be considered if:

● There is parental concern about any school­related problem (eg, behavioral regulation, poor peer interactions, or learning problems)

● The child's report card indicates learning difficulty, especially if there is a pattern of learning difficulty consistent with LD

● There is a family history of learning problems

● The child has a behavioral/mental health condition

● The child has a history of developmental delay

● The child has a neurologic or genetic condition or history of central nervous system insult (seizure disorders, neurofibromatosis, tuberous sclerosis complex)

(See "Specific learning disabilities in children: Clinical features", section on 'Risk factors'.)

MEDICAL EVALUATION — Learning disability (LD) does not usually have a defined medical cause. The goal of the medical evaluation is to identify potential medical, neurologic, and/or behavioral conditions that may be related to the LD or that may co­occur with the LD. The primary care provider often is already aware of co­ occurring behavioral, neurologic, or genetic conditions related to learning failure. If such conditions are present, it is particularly important to ask about learning and school problems during regularly scheduled well­child visits [1,9]. The child's report card is a useful source of information about the child's learning abilities.

History — The educational and learning histories are the most important aspects of the medical evaluation, particularly if the child has been followed consistently by the primary care provider and the provider is familiar with the child's medical conditions. https://www.uptodate.com/contents/specific­learning­disabilities­in­children­role­of­the­primary­care­provider/print 2/34 5/23/2017 Specific learning disabilities in children: Role of the primary care provider ­ UpToDate The chief complaint of the parent or child usually suggests the problem area [10]. The health care provider should use standard descriptors to further define the type of learning problem (eg, the time that the learning problem was first identified, any improvement or worsening of the problem over time, factors that improved or aggravated the learning problem, etc). Students with learning problems often have impairments in more than one area, including vision, hearing, motor skills, attention and task completion skills, language skills, and social skills. The pediatric clinician should ask about problems in these areas, in addition to asking about problems in formal learning at school.

The child's performance at school can be measured by report cards, teacher comments, parent observations, and history of academic progress over time. The Vanderbilt teacher questionnaire for attention deficit hyperactivity disorder is available through the National Institute for Children's Health Quality. It includes questions about classroom performance and co­occurring conditions, and can be useful in identifying learning difficulty. In the author's clinic, a detailed questionnaire about the student's school performance helps to complete the history when filled out by the classroom teacher (available from the Floating Hospital for Children Center for Children with Special Needs). Rating scales such as the Conners' rating scale [11], Childhood Behavior Checklist [12], and Behavioral Assessment System for Children, second edition [13,14] include pertinent questions about the child's behaviors in the classroom and are also a useful source of information about the student's classroom performance when completed by the classroom teacher.

It is important to assure that the child has attended school regularly when making an assessment for LD. The likelihood of LD increases if learning failure is associated with certain medical, developmental, and familial factors. Consideration of these factors also informs the treatment plan [1,9,10]. (See "Specific learning disabilities in children: Clinical features", section on 'Risk factors'.)

Important aspects of the history for a child in whom LD is being considered are listed in the table (table 1). The examiner should ask about the age of attainment of various developmental milestones, particularly language milestones (table 2 and figure 1). Past developmental delays can be associated with current learning problems.

The child's abilities and strengths should be identified, as well as his/her disabilities. One way to access this information is to ask what activities the child enjoys doing or believes him/herself to be good at doing. The child's interests and skills are useful in the development of a treatment plan.

Examination — The physical examination of most children with LD is normal. Abnormalities on physical examination may suggest a particular neurologic or genetic condition that is associated with learning problems (eg, neurofibromatosis, tuberous sclerosis complex, Klinefelter syndrome). However, children with these conditions typically do not present with learning failure as the first sign or symptom. Important aspects of the physical examination of a child in whom LD is a consideration are listed in the table (table 3).

Dysmorphic features (ie, major or minor malformations) may suggest a genetic or congenital condition that is associated with learning problems (see "Birth defects: Epidemiology, types, and patterns", section on 'Malformations'). The incidence of minor malformations is increased among children with LD [15]. However, no specific pattern of minor anomalies is pathognomonic for LD [16].

The child's participation in the history­taking and the physical examination provides an opportunity to review his or her capacity to follow instructions and to use language to answer questions and participate in a conversation.

Informal testing — The pediatric health care provider can perform informal testing to review developmental functions (table 2 and figure 1) and to identify specific areas for further testing [17]. Testing can also help in assessing basic knowledge and mental status. A formal battery of psychoeducational tests is usually administered by a psychologist or educator, but some primary care providers may use developmental assessment tools to add

https://www.uptodate.com/contents/specific­learning­disabilities­in­children­role­of­the­primary­care­provider/print 3/34 5/23/2017 Specific learning disabilities in children: Role of the primary care provider ­ UpToDate to the information that they have gathered. (See "Specific learning disabilities in children: Evaluation", section on 'Psychometric tests'.)

There are many components to successful learning. When LD is suspected, the primary care provider should focus on the specific learning skills and learning deficits that are characteristic of LD (table 1). However, other behaviors or learning difficulties, such as poor attention span or problems socializing, may be the signal for LD and/or may co­occur with the LD. Participation in structured developmental tasks can help the pediatric health care provider look more closely at the child's:

● Capacity to focus attention

● Language and memory function (ability to understand, remember, and carry out instructions)

● Expressive language skills (ability to use vocabulary and grammar correctly)

● Pragmatic language skills (use of nonverbal communication skills such as facial expressions, gestures, or changes in tone of voice; ability to carry on a conversation by providing appropriate responses and by showing appropriate turn­taking; being able to sequence sentences into a logical narrative)

● Coordination skills

● Specific tasks of reading, writing, or math (table 1)

The pediatric health provider can incorporate some routine questions about phonologic skills, reading, and language skills during office encounters with young children to assess language and literacy skills (table 4):

● Phonologic awareness skills – Preschool and kindergarten children should be able to identify and provide words that rhyme ("Tell me what rhymes with 'mat.'").

Grade one children should be able to delete the beginning sound of a word ("Say 'fireman' without saying 'man.'", "If you take away the 'h' sound from 'hat,' what do you get?") and replace the beginning sound of a word with a new letter ("If you take the 't' sound in 'take' and replace it with an 'm,' what do you get?").

● Early phonics skills – Kindergarten children should be able to identify letters and some of their sounds (sound­symbol relationships or phonics skills).

By the end of grade one, students should be able to read (decode) novel three and four letter words. Phonics is largely mastered by the end of grade two. In grade two, children can show phonetic spelling skills, producing phonetically correct words even if the words are spelled incorrectly.

● Late phonics skills – By the end of grade three, all phonics skills in the English language should be mastered, and the child should be able to read (decode) fluently/smoothly. The child should also be able to read with comprehension. By the end of grade three, spelling errors are less and less common in children who are learning successfully.

● Language skills – After age four, articulation should be 100 percent intelligible. By kindergarten or grade one, children should speak English fluently and without grammatical errors. Although grammatical errors amongst children exposed to another language at home can occur after this age, especially if exposed to incorrectly spoken English, children exposed to another language at home typically should have mastered English by this age as well. Review of language skills is especially useful because language difficulty typically precedes problems in reading and writing.

Inability to demonstrate the language and literacy skills listed above can signal potential reading/writing disorders. All children with problems with phonics have difficulty in both reading and writing. At all ages, difficulty https://www.uptodate.com/contents/specific­learning­disabilities­in­children­role­of­the­primary­care­provider/print 4/34 5/23/2017 Specific learning disabilities in children: Role of the primary care provider ­ UpToDate pronouncing basic sounds, mispronunciation of long or complicated words, halting speech, laborious and slow reading or writing, poor spelling, and/or the need for extra time in reading and/or to take tests are important indicators of a potential reading disorder (table 5 and table 6). Although additional evaluation is necessary, the primary care provider should have a high suspicion for a reading disorder and a low threshold for referral. (See "Reading difficulty in children: Clinical features and evaluation", section on 'Clinical features'.)

Routine questions about math skills may facilitate early identification of math LD. Early math skills include the following:

● Number sense – By kindergarten, children understand that things can be counted and that some numbers are bigger than others. They understand concepts such as "more/less" and "bigger/smaller." They know that numbers are counted in a specific order.

● Math facts or math calculations – In grade one, children know that numbers can be added and learn specific addition and subtraction procedures. By the end of grade two, they understand many math facts related to addition and subtraction, and can recite many of them by memorization. Multiplication and division skills are learned later.

● Math fluency – Math fluency refers to the quick retrieval of math facts. Math fluency is variable and is best assessed through formal measures.

Ancillary medical testing — There are no specific laboratory tests that are especially important or useful in the evaluation of LD unless indicated by the medical history and/or physical examination. However, it is crucial to assure normal hearing and vision. (See "Screening tests in children and adolescents", section on 'Hearing screen' and "Screening tests in children and adolescents", section on 'Vision screen'.)

MANAGEMENT — The primary care provider may play several roles in the management of learning disabilities (LD) in children. These include:

● Assisting in the evaluation of LD and co­occurring conditions (see 'Early identification' above and 'Medical evaluation' above)

● Requesting an LD evaluation by the child's school district

● After the comprehensive evaluation for LD, explaining the nature of the child's disability and any co­occurring conditions to the caregivers and patient (if developmentally appropriate) (see 'Education and counseling' below)

● Providing information about the legal rights of the child under Every Student Succeeds Act (ESSA), Section 504 of the Rehabilitation act (table 7), and the Individuals with Disabilities Education Act (IDEA) (see 'Advocacy and support' below and "Definitions of specific learning disability and laws pertaining to learning disabilities in the United States", section on 'Laws affecting the education of students with disabilities')

● Coordinating care under a medical home model and providing treatment for co­occurring conditions, including medication management when appropriate (see "Children with special health care needs", section on 'Medical home')

● Advocating on behalf of the family when they are unable to do so on their own

● Mediating between the family and the school team (see 'Mediator' below)

● Serving as a consultant and information resource for the school team (see 'Communicating with the school team' below) https://www.uptodate.com/contents/specific­learning­disabilities­in­children­role­of­the­primary­care­provider/print 5/34 5/23/2017 Specific learning disabilities in children: Role of the primary care provider ­ UpToDate Education and counseling — Information that the pediatric clinician should share is listed in the paragraphs that follow and includes education and counseling about:

● Learning disabilities ● Nonstandard therapies ● Psychosocial management ● Legal rights ● Resources

Learning disabilities — After a child is diagnosed with an LD, the primary care provider can provide information about the nature of LD and its management.

● Interpretation of evaluation reports (see "Specific learning disabilities in children: Evaluation", section on 'Formulas used to identify LD')

● A description of the specific skills that may be delayed and that should be the focus of intervention in LD (eg, phoneme awareness and phonics; reading comprehension; spelling instruction; number sense; organizational skills, etc) (see "Specific learning disabilities in children: Clinical features", section on 'Clinical features' and "Specific learning disabilities in children: Clinical features", section on 'LD syndromes')

● A description of the types of treatments and accommodations required by students with LD (see "Specific learning disabilities in children: Educational management", section on 'Quality instruction for LD')

● Information about the developmental and mental health conditions that frequently co­occur with LD (eg, language disorder, attention deficit hyperactivity disorder [ADHD], behavior disorders, anxiety, depression) and counseling about the social isolation that can sometimes occur as a result of LD and its co­occurring conditions (see "Specific learning disabilities in children: Clinical features", section on 'Comorbidities')

Nonstandard therapies — Parents of children with learning disability (LD) may learn about new therapies or management strategies from popular books, newspapers, magazines, the internet, or broadcast media [18]. Parents should be encouraged to consult educational experts regarding unproven therapies, since these therapies may lack the support of research data and may be proposed to the public before they are replicated and evaluated using valid scientific methods [10,19]. Nonstandard therapies for LD include neurologic training to correct or retrain sensory pathways and include patterning, optometric visual training, treatment of cerebellar­ vestibular dysfunction, applied kinesiology, and colored overlays or lenses (Irlen overlays or lenses) [18­22]. There is no evidence to support the use of these therapies in the treatment of LD [23­30]. Other unproven, nonstandard therapies include the elimination of food dyes, the use of megavitamins, the supplementation of polyunsaturated fatty acids, the supplementation of trace mineral elements, and a diet to treat hypoglycemia [18,19,31].

Psychosocial management — In conjunction with instructional methods to increase academic skills, children with LD may benefit from support or psychologic counseling, behavior modification, and social­skills training to reduce the primary or secondary emotional and behavioral problems that are associated with LD (eg, anxiety, withdrawal, depression, conduct disorders) [8,10,19,32]. The family can also play an important positive role in the adjustment to and management of LD.

Psychologic counseling may be useful for the following situations:

● Repair of the child's self­esteem ● Development of behavioral goals and the management of behavior ● Restoration of self­regulation or discipline at home and at school https://www.uptodate.com/contents/specific­learning­disabilities­in­children­role­of­the­primary­care­provider/print 6/34 5/23/2017 Specific learning disabilities in children: Role of the primary care provider ­ UpToDate ● Restoration of a significant adult­child relationship ● Support of the child or family through a crisis situation ● Treatment of comorbid secondary anxiety, depression, etc

The self­esteem and social skills of children with LD can be enhanced through participation in activities outside of school, particularly activities in which the child or adolescent can excel (eg, sports, music, drama, arts and crafts) [8,10,19,33]. Children who are reluctant to participate in team sports may benefit from independent activities, such as martial arts, swimming, diving, horseback riding, skiing, bowling, or track and field. Children with LD also may experience a sense of accomplishment through the completion of assigned responsibilities at school or home. The tasks that are chosen should be ones that the child is likely to perform successfully [19].

The attitudes, behaviors, and emotional support provided by the family of an individual with LD influence the resiliency and success of the individual [33­35]. Characteristics such as the ability to plan the steps required to achieve a goal (executive functions) and a sense of self­efficacy enable the child or adolescent to generate positive responses from themselves and from others, which can help overcome the frustration of learning tasks that are difficult for them. The presence of supportive adults, in addition to a child's parents (eg, grandparents, mentors, coaches, members of a church group) and the existence of appropriate opportunities at major life transitions, also helps students with LD cope with their disability [36]. Parents, siblings, and other caregivers affect the development of self­esteem and self­efficacy through their attitudes and behaviors. Strategies that encourage the development of resiliency among children and adolescents with LD are outlined in the table (table 8) [37].

Legal rights — Families of children with LD may ask the primary care provider to provide information about their child's legal rights in the school setting. They may obtain this information from other sources, such as the Center for Parent Information and Resources, the Council for Exceptional Children, or from other agencies (table 9). However, families do not always know how to interpret or use the information that they obtain and may turn to the primary care provider for guidance.

The primary care provider can provide counseling to the family about the rights offered under ESSA, IDEA, and Section 504 of the Rehabilitation Act (table 7) [38,39]. ESSA offers many services under general education to the student body as a whole. Most students with disabilities have rights under either the IDEA or under Section 504 of the Rehabilitation act (which is subsumed under the Americans with Disabilities Act [ADA] (table 10)), as long as they meet the functional impairment criteria set out by these laws. (See "Definitions of specific learning disability and laws pertaining to learning disabilities in the United States", section on 'Laws affecting the education of students with disabilities'.)

Resources — A list of resources for health care providers, patients, and families of children with LD is provided in the table (table 9).

Pediatric clinicians are encouraged to review Current Procedural Terminology (CPT) codes in their state to determine how the cost of consultation time with families can be recuperated. In the author's clinic, visits that are focused on counseling and the education of the family are billed using office visit codes, indicating the duration (number of minutes) of the encounter. The clinic notes document that counseling was provided to the family "for greater than 50 percent of the total time spent with the family."

Care coordination — Care coordination is one of the primary responsibilities of the primary care provider for the child with LD. Children with LD may require referral for evaluation and treatment of genetic, neurologic, and/or mental health conditions, and oversight of the treatment of such conditions.

In the role of care coordinator, the primary care provider also may make referrals to community agencies that provide supplementary instruction, training in behavioral regulation, opportunities to build social skills, support for the parents, etc. Sample resources and agencies to which families can be referred are listed in the table (table 9). https://www.uptodate.com/contents/specific­learning­disabilities­in­children­role­of­the­primary­care­provider/print 7/34 5/23/2017 Specific learning disabilities in children: Role of the primary care provider ­ UpToDate In addition, the pediatric clinician should refer to local mental health agencies and/or to a developmental pediatrician, child neurologist, or child psychiatrist who is familiar with the needs of students with LD when the explanation for learning failure is unclear or for the management of co­occurring conditions.

Pediatric clinicians are encouraged to review CPT codes in their state to determine how the cost of care coordination can be recuperated. The American Academy of Pediatrics (AAP) offers guidance on the use of CPT care coordination codes, though the time spent on care coordination may not be reimbursed consistently.

Advocacy and support — Parents may find it difficult to advocate for their child when they are new to the role of advocate, unfamiliar with the diagnosis of LD or their child's legal rights, or when they have a disability themselves (eg, language disability, learning disability, mental health condition). The primary care provider can provide advocacy and support for children and families of children with learning difficulty by:

● Helping them to organize their thoughts before communicating with the school team or by speaking to the school team on their behalf. Examples include: helping the family to organize their questions and requests before an individualized education program (IEP) meeting; communicating the family's concerns on their behalf during a telephone conversation with the school team; attending an IEP meeting with the family or suggesting that a family friend, another family member, or a hired advocate attend the meeting with them. The author of this topic review sometimes uses the office encounter to conduct a telephone meeting with the school team with the family present.

The following features of the IEP in a child with LD merit review with the family:

• Educational objectives – Educational objectives should address all areas of suspected disability. In addition, educational objectives should be measurable. Without measurable objectives, it is not possible to assess the student's progress. In the case of LD, educational objectives include areas such as improving phonologic skills (identifying and producing all of the sounds of the English language); phonics skills (identify how sounds of the English language are related to symbols [letters]); spelling skills; reading and writing fluency; as well as reading comprehension and written expression. Educational objectives for math can include improving number sense, improving math calculations, and improving fluency in math calculations, among others.

• Availability of appropriately trained staff to address all areas of suspected disability – In the case of LD, the teacher must be qualified to remediate/improve reading, writing, and/or math skills.

• Staff­to­student ratio – Small group instruction is needed to remediate LD. For specialized instruction in phonics, for example, group size should be one teacher to three students maximum.

• A classroom setting that is conducive to addressing the student's individual needs (eg, general education setting versus other settings).

• Consultation and collaboration among staff to ensure that educational objectives are addressed across the curriculum.

• Research­based curriculum – Research­based curricula apply predominantly to reading instruction. However, curricula typically are not described in the IEP; this information must be specifically requested.

● Providing information about the child's behavioral and medical needs to the school team. (See 'Communicating with the school team' below.)

● Helping them understand education law. (See 'Legal rights' above and "Definitions of specific learning disability and laws pertaining to learning disabilities in the United States", section on 'Laws affecting the education of students with disabilities'.) https://www.uptodate.com/contents/specific­learning­disabilities­in­children­role­of­the­primary­care­provider/print 8/34 5/23/2017 Specific learning disabilities in children: Role of the primary care provider ­ UpToDate ● Advocating for services when the primary care provider believes they are needed and were not offered by the school team. (See 'Mediator' below.)

● Helping the family to understand why the school team may have decided not to provide services when the family believes the child is in need of services. (See 'Education and counseling' above and 'Service delivery decisions: Primary care provider's role' below.)

To be a successful advocate, the primary care provider must [40]:

● Have a working knowledge of psychometric measures and their interpretation (see "Specific learning disabilities in children: Evaluation", section on 'Psychometric tests' and "Specific learning disabilities in children: Evaluation", section on 'Formulas used to identify LD')

● Understand the varying ways in which special education teams make decisions regarding eligibility for special education (see "Specific learning disabilities in children: Evaluation", section on 'Determination of service eligibility')

● Understand the limitations of service obligations of schools under education law (see "Specific learning disabilities in children: Evaluation", section on 'Evaluation and identification of LD in school settings' and "Definitions of specific learning disability and laws pertaining to learning disabilities in the United States", section on 'Laws affecting the education of students with disabilities')

At the community level, the primary care provider may advocate for children with learning disabilities by becoming a member of the school committee or collaborating with school administrators to assure systems that identify and serve children with disabilities [6].

Mediator — Pediatric health care providers may take on the role of mediator when a family is in disagreement with the school team about the provision of services for their child and asks the provider for advice. In such situations, the primary care provider can start by determining whether the family has a correct understanding of their legal rights and whether the school team has fulfilled the procedural safeguards required by law (eg, under the IDEA, an evaluation has to be made available at public expense and upon parent request; the evaluation has to be completed within 60 days, etc). (See "Definitions of specific learning disability and laws pertaining to learning disabilities in the United States", section on 'Laws affecting the education of students with disabilities'.)

Next, it is important to understand the family's disagreement and why they believe that a service for their child is needed. Following this, it is often helpful to call a member of the child's school team, such as the special education coordinator or the school principal, to learn about why the conflict may have arisen. Sometimes, sharing perspectives between the family and the school team is sufficient to help each party see "eye to eye." At other times, when the family has a valid reason for disagreement, they may need to be referred to advocacy services or other clinicians who may be more experienced in managing situations of conflict, such as a developmental behavioral pediatrician, a child psychologist or psychiatrist who understands the needs of children who require special education services, or an advocate or other professional at a regional parent technical assistance center (table 9). The family can also seek redress through mediation or by due process hearings through the state board of education.

Communicating with the school team — Many pediatric clinicians are interested in participating in school health programming, which includes providing for the physical and mental health needs of students [41]. Pediatric clinicians have much to offer to school professionals and can help improve services for students when they communicate effectively with the school team. School teams typically value the input of clinicians and other medical personnel. However, they can also experience significant frustration in their interactions with medical personnel, specifically when medical personnel do not communicate with schools [42]. One of the major reasons that schools hire a pediatric consultant is to assure effective communication between the school team and the https://www.uptodate.com/contents/specific­learning­disabilities­in­children­role­of­the­primary­care­provider/print 9/34 5/23/2017 Specific learning disabilities in children: Role of the primary care provider ­ UpToDate child's health care provider [43]. This speaks to the importance of communication that occurs directly between pediatric clinicians and the child's school team members.

All communication between the primary care provider and members of the school team should occur with the knowledge and agreement of the family. The child psychiatry literature offers guidelines and suggestions for how to consult with school teams, which can help inform how the primary care provider should consult with school teams [44,45]. Effective communication with school teams improves with practice and over time.

When communicating with schools, personally or in writing, it is important for the primary care provider to understand the type of information most needed by schools; the legal weight of recommendations provided by a pediatric clinician when the school makes service delivery decisions; and the circumscribed nature of therapeutic services in school settings. These aspects of communication are described in the following sections.

Medical information

● About medical conditions – The type of information that is most useful to schools concerns diagnoses that they are not able to make on their own (eg, medical or mental health conditions, such as epilepsy, attention deficit disorder, autism, etc), and information about the effects of the condition(s) and/or its treatment(s) on the child's ability to learn. A major concern for many school professionals is the wish to avoid harming the student, either through action or inaction related to the student's medical or mental health conditions. The pediatric clinician can help address these concerns, but personal communication with the school team may be required to assure that the correct questions are answered.

● About prescriptions – The school team may require explicit or prescriptive information from the pediatric clinician. This typically applies to the administration of medications or other medical interventions at school, rather than prescriptions for rehabilitative services. (See 'Services at school: Educational versus rehabilitative' below.)

To assure that medications or other interventions are administered or used appropriately, personal communication with the school nurse may be required. Subspecialists may need to provide information for certain interventions (eg, orthotic devices, ventilators, etc). Specific guidelines about the use of medications in schools are available from the AAP [46]. Of note, the IDEA specifically prohibits any requirement that parents seek the use of medications before evaluations or services are provided by the school [47].

● About the student's capacity to participate at school – The school team may require information about potential effects of the student's medical condition(s) or treatment(s) on the student's performance in the classroom or other school­related activities. This information may need to be very explicit in order for the student to receive the necessary evaluations and/or services. It may include comments about the student's capacity to navigate the school environment; capacity to remain seated for the duration of the school day; capacity to follow school rules and classroom routines; ability to participate in classroom discussions; capacity to focus; capacity for peer relations; ability to complete classroom work and homework, etc. Pediatric health care providers are not necessarily trained to think about the functional or educational needs of students in school settings and may not be certain about how to describe the functional impact of the child's condition on his or her performance at school or to make recommendations that reflect all of the student's needs. In such situations, it is best for the pediatric clinician to speak directly with classroom staff and then make an estimate about how the student's medical or behavioral conditions might be related to classroom performance. A convenient way to obtain this information is to have the classroom teacher describe his or her concerns about the student's performance in class or to complete a questionnaire about school function. The questionnaire used in the author's clinic is available from the Floating Hospital for Children Center for Children with Special Needs.

https://www.uptodate.com/contents/specific­learning­disabilities­in­children­role­of­the­primary­care­provider/print 10/34 5/23/2017 Specific learning disabilities in children: Role of the primary care provider ­ UpToDate ● About testing or services needed – Based on the information gathered about the student, the pediatric clinician can make recommendations for testing (eg, screening evaluation for mental health conditions, speech/language testing, occupational therapy testing, educational evaluation, etc) or make recommendations for specific kinds of services (eg, behavior management, counseling, instruction in social interactions, LD instruction, etc).

In order to maximize the chances that educational recommendations made by a pediatric clinician will be considered thoughtfully, the pediatric clinician must have information about the child's performance at school, either in the form of a questionnaire about school performance (eg, the school questionnaire available from the Floating Hospital for Children Center for Children with Special Needs, Vanderbilt Assessment Scales ) or by having a conversation with a member of the school team. Recommendations made by the pediatric clinician following a conversation with a school team member are more likely to reflect the student's actual needs and to be considered favorably by the school. When recommendations are provided in writing, the author typically includes a statement, such as, "the following recommendations were discussed with the student's school team on (mention date)," to show the reader of the document that the school team's perspective was considered before the recommendations were made. This type of thoughtfulness is highly valued by schools.

Written documentation — Families may ask the primary care provider to provide written documentation of their child's diagnosis (or diagnoses) or a "prescription" for education or related services at school. Requests for diagnostic information may be requested by the school as a routine.

Sharing diagnostic information is typically a straightforward process. However, it is helpful if the primary care provider reminds the family that having a specific diagnosis or a disability does not guarantee the provision of services: It is the functional impairment of the disability that determines whether services are provided [48]. (See 'Service delivery decisions: Primary care provider's role' below.)

It is helpful for the pediatric clinician to understand the context in which the information is being requested. As an example, the family may request a "prescription" or letter from the primary care provider making a request for specific evaluations or service. Such a request may be related to conflict between the family and the school about service delivery decisions [49].

When specific recommendations for testing or services are sought by the family, the pediatric clinician can call the school to find out why the letter or prescription is being sought and to find out what information or recommendations would be most useful to the school team. Communication with the school increases the chance that the written documentation will result in action on the part of the school. In some cases, failure to communicate with the school can inadvertently reinforce conflicts between the family and the school [42]. Sometimes, verbal communication obviates the need for written documentation, simply because the pediatric clinician has spoken on behalf of the family and has helped the school team to understand the family's needs or concerns. In most cases, written documentation from the pediatric clinician is more useful to the school team and received more positively when there has been a prior conversation with a member of the school team.

Service delivery decisions: Primary care provider's role — The law requires schools to make service delivery decisions collaboratively. This means that schools make decisions by "considering" (a legal term found in the IDEA) the input of outside providers (including the primary care provider), along with the input of school team members and the family [50]. No single clinician, teacher, or administrator is allowed to determine how services are to be delivered. This process, when conducted successfully, allows the school team to consider options for service delivery that are therapeutically and educationally sound but that also are consistent with the school ecology and resources as a whole. That being said, service delivery decisions are sometimes made on the basis of the services available at the school, not on the basis of the services needed by the student. In such cases, https://www.uptodate.com/contents/specific­learning­disabilities­in­children­role­of­the­primary­care­provider/print 11/34 5/23/2017 Specific learning disabilities in children: Role of the primary care provider ­ UpToDate input from the pediatric clinician that reveals an understanding of the student's needs at school can carry significant weight in service delivery decisions at school.

Schools sometimes appear to make service delivery decisions contingent upon the pediatric clinician's input. Families and even school teams sometimes believe that the pediatric clinician's input is a requirement for the delivery of certain kinds of services at school (eg, specialized services for a student with a diagnosis of autism or supportive services for a student with ADHD). However, neither Section 504 of the Rehabilitation Act nor the IDEA supports the practice of withholding services until a diagnosis is "proven" to exist or until a health care provider's input is received. First, schools cannot require the family to use insurance benefits in order to obtain the information that the school needs to make service decisions. Second, although a handicapping condition is a prerequisite for the delivery of services under both Section 504 and the IDEA, it is the functional impairment that determines the services provided, not the diagnosis or condition [48]. This functional impairment is evaluated by the school team, not by the pediatric clinician. Schools have great legal latitude in providing services to students who may need them. Education and disability rights laws include many provisions to assure successful service delivery to student without the input of any outside clinicians.

Services at school: Educational versus rehabilitative — Schools provide therapeutic services that are related to the student's education [6,40,51]. They do not offer therapeutic services in a rehabilitative mode of care. Medical services and interventions that are offered in schools are circumscribed to assure that the student can receive a "meaningful benefit" from his or her individualized educational program under the Individuals with Disabilities Education Act [52] and/or to prevent discrimination by providing equal access to an education program under the Americans with Disabilities Act (table 10). (See "Definitions of specific learning disability and laws pertaining to learning disabilities in the United States", section on 'Laws affecting the education of students with disabilities'.)

Thus, for example, physical therapy and occupational therapy services are provided to assure that the student can navigate successfully the school environment, remain seated and participate in classroom discussion, and complete any of the other fine or gross motor tasks required in the school setting. Similarly, speech/language services are provided so that the student can participate in classroom discussions, complete reading and writing tasks, and interact with peers. Providing services and supports to the student is geared specifically to supporting those activities required at school. Given the many tasks required by students in school, students often do receive services that provide rehabilitative benefits since the distinction between "rehabilitative" and "educational" is not always clear. However, the pediatric clinician should understand that rehabilitation is not the intent of education or civil rights laws. Some rehabilitative services can and should be accessed through the child's health insurance plan, allowing the child to focus on his or her education while in the school setting.

SUMMARY

● The primary responsibilities of the primary care provider in the care of the child with learning disability (LD) are to assist in the diagnosis and management of LD and its co­occurring conditions, and to provide case management under a medical home model. (See 'Overview' above.)

● Early identification of LD is crucial to providing appropriate interventions. Pediatric health care providers should have a low threshold for considering LD in children who are at risk for LD and children who have problems at school. (See 'Early identification' above.)

● The goal of the medical evaluation is to identify potential medical, neurologic, and/or behavioral conditions that may be related to the LD or that may co­occur with the LD. Important aspects of the history and examination are provided in the tables (table 1 and table 3). It is crucial to assure normal hearing and vision. (See 'Medical evaluation' above.)

https://www.uptodate.com/contents/specific­learning­disabilities­in­children­role­of­the­primary­care­provider/print 12/34 5/23/2017 Specific learning disabilities in children: Role of the primary care provider ­ UpToDate ● Once a child has been diagnosed with a learning disability, the primary care provider should coordinate care and provide treatment for co­occurring conditions. (See 'Care coordination' above.) Additional roles may include:

• Provision of education and counseling about LDs and the child's legal rights (table 9) (see 'Education and counseling' above)

• Advocacy and support for the child and family (see 'Advocacy and support' above)

• Mediating between the family and the school team (see 'Mediator' above)

• Serving as a consultant and information resource for the school team (see 'Communicating with the school team' above)

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REFERENCES

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17. Hagerman RJ. Pediatric assessment of the learning­disabled child. J Dev Behav Pediatr 1984; 5:274. 18. Silver LB. Nonstandard therapies of learning disabilities. Semin Neurol 1991; 11:57. 19. Silver LB. The Misunderstood Child: A Guide for Parents of Learning Disabled Children, McGraw­Hill, New York 1984. 20. McInerny TK. Children who have difficulty in school: a primary pediatrician's approach. Pediatr Rev 1995; 16:325. 21. Ziring PR, brazdziunas D, Cooley WC, et al. American Academy of Pediatrics. Committee on Children with Disabilities. The treatment of neurologically impaired children using patterning. Pediatrics 1999; 104:1149. 22. Ritchie SJ, Della Sala S, McIntosh RD. Irlen colored overlays do not alleviate reading difficulties. Pediatrics 2011; 128:e932. 23. American Academy of Pediatrics, Section on Ophthalmology, Council on Children with Disabilities, American Academy of Ophthalmology, American Association for Pediatric Ophthalmology and Strabismus, American Association of Certified Orthoptists. Joint statement­­Learning disabilities, dyslexia, and vision. Pediatrics 2009; 124:837. 24. Keogh BK, Pelland M. Vision training revisited. J Learn Disabil 1985; 18:228. 25. Beauchamp GR. Optometric vision training. Pediatrics 1986; 77:121. 26. Kavale K, Mattson PD. "One jumped off the balance beam": meta­analysis of perceptual­motor training. J Learn Disabil 1983; 16:165. 27. Solan HA. An appraisal of the Irlen technique of correcting reading disorders using tinted overlays and tinted lenses. J Learn Disabil 1990; 23:621. 28. Black JL, Collins DW, De Roach JN, Zubrick S. A detailed study of sequential saccadic eye movements for normal­ and poor­reading children. Percept Mot Skills 1984; 59:423. 29. Sadun AA. Dyslexia at The New York Times: (mis)understanding of parallel visual processing. Arch Ophthalmol 1992; 110:933. 30. Handler SM, Fierson WM, Council on Children with Disabilities, et al. Learning disabilities, dyslexia, and vision. Pediatrics 2011; 127:e818. 31. Tan ML, Ho JJ, Teh KH. Polyunsaturated fatty acids (PUFAs) for children with specific learning disorders. Cochrane Database Syst Rev 2016; 9:CD009398. 32. Fleischner JE. Educational management of students with learning disabilities. J Child Neurol 1995; 10 Suppl 1:S81. 33. Lock RH, Janas M. Build Resiliency. Intervention in School & Clinic 2002; 38:117. 34. Hermans H, van der Pas FH, Evenhuis HM. Instruments assessing anxiety in adults with intellectual disabilities: a systematic review. Res Dev Disabil 2011; 32:861. 35. Raskind MH, Gerber PJ, Goldberg RJ, et al. Longitudinal research in learning disabilities: report on an international symposium. J Learn Disabil 1998; 31:266. 36. Dole S. The implications of the risk and resilience literature for gifted students with learning disabilities. Roeper Review 2000; 23:91. 37. Smith C, Strick L. Strategies for Promoting Personal Success. Learning Disabilities: A to Z: A parent's complete guide to learning disabilities from preschool to adulthood, Free Press, New York, NY 1997. p.257. 38. The pediatrician's role in development and implementation of an Individual Education Plan (IEP) and/or an Individual Family Service Plan (IFSP). American Academy of Pediatrics. Committee on Children with Disabilities. Pediatrics 1999; 104:124. https://www.uptodate.com/contents/specific­learning­disabilities­in­children­role­of­the­primary­care­provider/print 14/34 5/23/2017 Specific learning disabilities in children: Role of the primary care provider ­ UpToDate 39. The role of the pediatrician in implementing the Americans with Disabilities Act: subject review. American Academy of Pediatrics Committee on Children with Disabilities. Pediatrics 1996; 98:146. 40. American Academy of Pediatrics Council on Children With Disabilities, Cartwright JD. Provision of educationally related services for children and adolescents with chronic diseases and disabling conditions. Pediatrics 2007; 119:1218. 41. Bartlett L. Medical services: the disputed related service. J Spec Educ 2000; 33:215. 42. von Hahn L, Linse C, Hafler J. Hospital assessments of children with learning problems: perspectives from special education administrators and hospital evaluators. Ambul Pediatr 2002; 2:11. 43. Taras H, Brennan JJ. Students with chronic diseases: nature of school physician support. J Sch Health 2008; 78:389. 44. Milam­Miller S. The psychiatrist as consultant: working within schools, the courts, and primary care to promote children's mental health. Psychiatr Clin North Am 2009; 32:165. 45. Walter HJ, Berkovitz IH. Practice parameter for psychiatric consultation to schools. J Am Acad Child Adolesc Psychiatry 2005; 44:1068. 46. Committee on School Health, American Academy of Pediatrics. Guidelines for the administration of medication in school. Committee on School Health. Pediatrics 2003; 112:697. 47. 34 CFR 300.174 Prohibition on mandatory medication. [school personnel cannot require] parents to obtain a prescription for substances identified under schedules I, II, III, IV, or V in section 202(c) of the Controlled Substances Act (21 U.S.C. 812(c)) for a child as a condition of attending school, receiving an evaluation under §§300.300 through 300.311, or receiving services under this part. Authority: 20 U.S.C. 1412(a)(25)) 48. Council for Exceptional Children. Understanding the differences between IDEA and Section 504. Teaching Exceptional Children 2002; 34:16. 49. Bateman B. The physician and the world of special education. J Child Neurol 1995; 10 Suppl 1:S114. 50. 34 CFR 300.502 Parent­initiated evaluations. Must be considered by the public agency, if it meets agency criteria, in any decision made with respect to the provision of FAPE to the child. Authority: 20 U.S.C. 1415(b)(1) and (d)(2)(A) 51. Cooley WC, American Academy of Pediatrics Committee on Children With Disabilities. Providing a primary care medical home for children and youth with cerebral palsy. Pediatrics 2004; 114:1106. 52. Zirkel P, Knapp S. Related services for students with disabilities: What educational consultants need to know. J Educ Psych Consult 1993; 4:137.

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GRAPHICS

Important elements of the history for students with learning failure

Potential significance

History of the learning problem

When did the family first notice learning problems in Persistent learning problems over time are more highly the child? Is the child learning successfully now or still associated with LD than a learning problem of recent struggling? onset; LD can first manifest at any time throughout the primary and elementary school years but usually manifests in the primary school years

What helps the child learn more successfully? (eg, Greater success in small groups as opposed to the small group instruction; 1:1 instruction, etc) general classroom may be related to LD or may be related to other factors such as a language disorder or weak executive skills

School performance

What are the child's grades? Past or current poor academic achievement is a significant risk factor for LD

Can the child complete homework independently? Inability to complete homework independently, especially after grade one, can indicate LD

Did the child receive any early intervention or special Past early intervention or special education services are a education services? significant risk factor for LD, regardless of the type of service that was offered and regardless of whether the child was found to be no longer eligible for services

Did the child's teachers provide any indication that they Not all teachers can identify LD specifically, and not all were concerned about the child's educational progress? teachers have access to a student support team to facilitate identification of LD; however, teacher observations of learning failure is a sensitive indicator of LD

Past grade retention Past grade retention is a significant risk factor for LD

School attendance

Does the child attend school regularly, now and in the Past school absences have a significant impact upon past? learning success and can mimic LD or be due to LD

Does the child have a history of school avoidance? School avoidance may be due to perceived lack of competence because of LD and may also lead to school absences, aggravating learning problems

Current psychiatric or behavioral conditions

Mental health conditions often occur with LD and are a risk factor for LD Ability to focus and sustain attention to complete tasks Symptoms of inattention are associated with attention of the daily routine; participate in social activities; deficit hyperactivity disorder, which is highly comorbid and/or complete homework independently with LD; LD can also cause inattention during academic tasks

Capacity to regulate anxiety, eg, separation anxiety Symptoms of anxiety are a risk factor for LD, either as a when leaving the home to go to school or elsewhere; comorbid condition or as a result of LD other symptoms of anxiety

Capacity for managing frustration (waiting his/her turn Symptoms of difficulty regulating anger are a risk factor in a game; capacity to self­soothe when angry) for behavior disorders, which are highly comorbid with LD; low frustration tolerance for school activities specifically is a significant risk factor for LD

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Prenatal health problems; prenatal exposure to Past neurologic insults are a risk factor for learning medications, toxins (alcohol, nicotine, etc) or infection problems in general and for LD

Perinatal course and complications Perinatal complications are a risk factor for learning problems in general and for LD

Gestational age; birth weight Prematurity is a risk factor for learning problems in general and for LD

Past illnesses, especially affecting the CNS Past neurologic insults are a risk factor for learning problems in general and for LD

Past lead exposure Lead exposure is associated with lower cognitive potential

Past or current medications Medications may interfere with CNS functioning and may be associated with learning failure

Current neurologic symptoms to suggest seizures Seizures can interfere with learning

Current sleeping habits Poor sleeping habits may interfere with learning success

Developmental history

Age­appropriate attainment of gross motor skills Motor problems are related to cerebral palsy and other neurologic conditions, which are comorbid with learning failure in general and may be associated with LD

Age­appropriate attainment of language skills Language problems are highly comorbid with LD

Age­appropriate attainment of adaptive skills such as Age­appropriate attainment of adaptive skills requires personal care, toileting general cognitive skills, as well as attention regulation skills; poor adaptive function may be associated with learning failure and with LD

Attainment of social and play skills (ability to play Social skills may be delayed as a primary problem (eg, successfully with same­age peers without parent autism spectrum disorder) or may be due to perceived supervision; capacity for friendships) lack of self­confidence due to LD

Able to participate in community activities such as Motor, adaptive, and social skills are required for success sports teams or other recreational activities in community activities; LD is associated with lower success in these areas

Family history

Do any first­ or second­degree relatives have learning LD is often inherited problems?

Do any first­ or second­degree relatives have mental Mental health conditions often occur with LD and are a health or developmental conditions such as anxiety, risk factor for LD depression, attention problems, learning problems, etc?

What are the parents' or family's current reading The history of current reading habits can serve as a proxy habits? for an unidentified reading disability

How far did the parents take their education? Poor educational achievement is related to LD

Social history

Current parent employment status Current parental employment status may be related to the parents' success at school and maybe an indicator of LD

Past abuse or neglect Past abuse or neglect is a significant risk factor for poor educational achievement in general and may be related to LD, regardless of current social status

Past or current homelessness Past homelessness is a significant risk factor for poor educational achievement in general and may be related to LD, regardless of current living circumstances

Past or current parental illnesses in family members Past illnesses in the family is a risk factor for poor educational achievement, for both social and heritable reasons

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Poor educational achievement may occur because of LD, weak language skills, weak executive skills, or lower overall cognitive potential. All of the risk factors listed above are associated with learning failure and strengthen the case for requesting an evaluation for LD or other causes of learning failure.

LD: learning disability; CNS: central nervous system.

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Developmental milestones: 4 years, 0 months through 7 to 8 years

Approximate chronologic age

4 years to 4 years, 6 5 years 5 years, 6 years to 6 years, 6 7 to 8 years months 6 months months

Gross motor Balances on one Walks down Tandem walks Rides bicycle foot: Four to eight stairs, Skips independently seconds alternating feet, Bats ball placed on Hops on one foot: without using cone Two to three times rail Does somersaults Standing broad Balances on jump: One to two one foot: More feet than eight Gallops seconds Throws ball Hops on one overhand: 10 feet foot: 15 feet Catches bounced ball Skips Running broad jump: Two to three feet Walks backward heel­toe Jumps backward

Fine motor/writing Copies square Copies triangle Builds stairs with Writing rate Imitates making a Builds stairs cubes* from increases complex gate with with cubes* memory Stays on line when cubes* from model Draws diamond writing Ties single knot Puts paper clip Copies flag Spaces between Cuts five inch circle on paper Writes first and last words Uses tongs to Can use name Size of letters transfer clothespins to Creates and writes becomes uniform Writes part of first transfer small short stories Letter reversals name objects Forms letters with disappear Works from left to Cuts with down­going and right, top to bottom scissors counter­clockwise Writes first strokes name

Self­help Goes to toilet alone Spreads with Ties shoes Sticks with tasks Wipes after BM knife Combs hair (with television off) Washes face/hands Independent Looks both ways at for up to 20 minutes Brushes teeth alone dressing street Pays attention to Buttons Bathes Remembers to independently teacher when in a Uses fork well bring belongings group Completes homework on own Answers and delivers phone messages Completes household chores (with reminders)

Cognitive/academic Draws a four­ to six­ Draws an 8­ to Draws a 12­ to 14­ Knows sounds of https://www.uptodate.com/contents/specific­learning­disabilities­in­children­role­of­the­primary­care­provider/print 19/34 5/23/2017 Specific learning disabilities in children: Role of the primary care provider ­ UpToDate part person 10­part person part person consonant digraphs Can give amounts Gives amounts Number concepts (eg, "ch," "sh") (usually less than (less than 10) to 20 Knows sounds of five) correctly Identifies coins Simple vowel diphthongs Completes simple Names addition/subtraction (eg, "oo," "ou") analogies (eg, letters/numerals Understands Reads words with dad/boy:mother/___, out of order seasons r­controlled vowels ice/cold:fire/___, Rote counts to Sounds out (eg, bird, burn) ceiling/up:floor/___) 10 regularly spelled Starts "reading to Points to five to six Names 10 words learn" not just colors colors By end of first "learning to read" Points to Uses letter grade: Reads 250 Two­place letters/numerals names as words addition/subtraction when named sounds to Enjoys reading Rote counts to four invent spelling independently "Reads" several (eg, "N­D­N" Remembers spelling common signs/store for "Indian") words names By end of kindergarten: Knows sounds of consonants and short vowels Reads 25 words

Social/emotional Deception: Interested Has a group of Has best friend of Avoids hurting in tricking others and friends same sex others in play concerned about Apologizes for Plays board games Learns from being tricked by mistakes Distinguishes mistakes others Responds fantasy from reality Helps younger Has a preferred verbally to Wants to be like children friend good fortune of friends and please Strong notions Labels happiness, others them about what is fair sadness, fear, and Enjoys school Takes turns in anger in self conversations Group play Delays gratification and waits to take turn Interested in the opinions of peers

Receptive language Follows three­step Knows right Asks what Understands commands and left on self unfamiliar words opposites and word Points to things that Points to mean analogies are the same versus different one in Can tell which Answers "who," different a series words do not "why," "when," Names things when Understands belong in a group "where," and "how" actions are described "er" endings questions (eg, it swims in (eg, batter, Knows right and water, you cut with it, skater) left on others it is something you Understands Understands days read, it tells time) adjectives (eg, and months bushy, long, thin, pointed) Enjoys rhyming words and alliterations Produces words that https://www.uptodate.com/contents/specific­learning­disabilities­in­children­role­of­the­primary­care­provider/print 20/34 5/23/2017 Specific learning disabilities in children: Role of the primary care provider ­ UpToDate rhyme Points correctly to "side," "middle," and "corner"

Expressive Repeats four­ to six­ Repeats six­ to Repeats 8­ to 10­ Masters "r" sound language syllable sentences eight­syllable word sentences in speech Uses 300 to 1000 sentences Describes events in Tells time words Defines simple an orderly way Uses complex and Tells stories words Knows days of the compound 100% intelligibility 2000 word week sentences with few articulation vocabulary 10,000 word Talks about a range errors Knows vocabulary of topics Uses "feeling" words telephone Uses words that tell number about time Responds to "why" questions Retells stories with clear beginning, middle, and end

BM: bowel movement. * Refer to UpToDate content on fine motor milestones.

© 2007 Chris Johnson, MD, AAP Council on Children with Disabilities. Adapted with permission and contributions from: Frances Page Glascoe, PhD and Nicholas Robertshaw, authors of PEDS: Developmental Milestones; Franklin Trimm, MD, Vice Chair of Pediatrics, USA/APA Education Committee; the Center for Disease Control "Act Early" Initiative; the National Institute for Literacy/Reach Out and Read; and the Inventory of Early Development by Albert Brigance published by Curriculum Associates, Inc. Permission is granted to reproduce these pages on the condition that they are only used as guide to average development and not as a substitute for standardized validated screening for developmental­behavioral problems.

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Fine motor milestones demonstrated with cubes according to age

These milestones are presented as a guide to average development and not as a substitute for standardized validated screening for developmental­behavioral problems.

Adapted from: 1. Frances Page Glascoe, PhD and Nicholas Robertshaw, authors of PEDS: Developmental Milestones; Franklin Trimm, MD, Vice Chair of Pediatrics, USA/APA Education Committee; the Center for Disease Control "Act Early" Initiative; the National Institute for Literacy/Reach Out and Read; and the Inventory of Early Development by Albert Brigance published by Curriculum Associates, Inc. 2. Capute AJ, Accardo PJ. The pediatrician and the developmentally disabled child: A clinical textbook on mental retardation, University Press, Baltimore 1979. https://www.uptodate.com/contents/specific­learning­disabilities­in­children­role­of­the­primary­care­provider/print 22/34 5/23/2017 Specific learning disabilities in children: Role of the primary care provider ­ UpToDate

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Important aspects of the examination of a child with learning difficulty*¶

Examination feature Potential clinical implicationΔ

General observations and appearance

Sadness, anxiety, attention Emotional or behavioral problems may affect learning span, impulsivity, activity

Ability to communicate and Measure of language skills other than phonologic processing respond to instructions

Stigmata of genetic syndromes Klinefelter syndrome: tall stature, small testes (eg, Klinefelter, Turner, fragile Turner syndrome: short stature, webbed neck, micrognathia, short metacarpals, X) nail dysplasia, widely spaced nipples

Fragile X syndrome: narrow face; large jaw; long, prominent ears; large testes (after puberty)

Growth parameters

Head circumference Head circumference <10th percentile may suggest fetal alcohol syndrome

Children with fragile X syndrome usually have head circumference >50th percentile

Height and weight Height and weight <10th percentile may suggest fetal alcohol syndrome

Short stature is a feature of Turner syndrome

Tall stature is a feature of Klinefelter syndrome

Skin

Café­au­lait spots, ash leaf Neurocutaneous disorders (eg, neurofibromatosis, tuberous sclerosis) are spots, adenoma sebaceum associated with learning problems

Genitalia

Delayed sexual maturation May be associated with Turner syndrome, Klinefelter syndrome

Small testes Suggestive of Klinefelter syndrome

Large testes (after puberty) Suggestive of fragile X syndrome

Sensory screening

Hearing assessment Hearing impairment may affect learning

Vision assessment Vision impairment may affect learning

Neurologic examination

Asymmetry, increased or Cerebral palsy decreased muscle tone

Coordination problems Developmental coordination disorder

Weakness Muscular dystrophy

Tics Tourette syndrome

Staring episodes Seizure disorder

* In this table, "learning disability" refers to a heterogeneous group of disorders characterized by the unexpected failure of an individual to acquire, retrieve, and use information competently, rather than intellectual disability (mental retardation). ¶ Most children with learning disability have a normal physical examination. Δ Learning disability is rarely the first manifestation of these disorders.

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Clues to dyslexia in early childhood

The preschool years

Trouble learning common nursery rhymes, such as "Jack and Jill" and "Humpty Dumpty"

A lack of appreciation of rhymes

Mispronounced words; persistent baby talk

Difficulty in learning (and remembering) names of letters

Failure to know the letters in his own name

Kindergarten and first grade

Failure to understand that words come apart; for example, that batboy can be pulled apart into bat and boy, and, later on, that the word bat can be broken down still further and sounded out as: "b" "aaa" "t"

Inability to learn to associate letters with sounds, such as being unable to connect the letter b with the "b" sound

Reading errors that show no connection to the sounds of the letters; for example, the word big is read as goat

The inability to read common one­syllable words or to sound out even the simplest of words such as mat, cat, hop, nap

Complaints about how hard reading is, or running and hiding when it is time to read

A history of reading problems in parents or siblings

Reproduced with permission from: Shaywitz S. Overcoming Dyslexia: A New and Complete Science­Based Program for Reading Problems at Any Level. Copyright © 2003 by Sally Shaywitz, M.D. Used with permission of Alfred A. Knopf, a division of Random House, Inc. For on­line information about other Random House, Inc. books and authors, see the Internet Web site at www.randomhouse.com.

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Clues to dyslexia from second grade on

Problems in speaking

Mispronunciation of long, unfamiliar, or complicated words; the fracturing of words­­leaving out parts of words or confusing the order of the parts of words; for example aluminum becomes amulium

Speech that is not fluent­­pausing or hesitating often when speaking, lots of um's during speech, no glibness

The use of imprecise language, such as vague references to stuff or things instead of the proper name of an object

Not being able to find the exact word, such as confusing words that sound alike: saying tornado instead of volcano, substituting lotion for ocean, or humanity for humidity

The need for time to summon an oral response or the inability to come up with a verbal response quickly when questioned

Difficulty in remembering isolated pieces of verbal information (rote memory)­­trouble remembering dates, names, telephone numbers, random lists

Problems in reading

Very slow progress in acquiring reading skills

The lack of a strategy to read new words

Trouble reading unknown (new, unfamiliar) words that must be sounded out; making wild stabs or guesses at reading a word; failure to systematically sound out words

The inability to read small "function" words, such as that, an, in

Stumbling on reading multisyllable words, or the failure to come close to sounding out the full word

Omitting parts of words when reading; the failure to decode parts within a word, as if someone had chewed a hole in the middle of the word, such as conible for convertible

A terrific fear of reading out loud; the avoidance of oral reading

Oral reading filled with substitutions, omissions, and mispronunciations

Oral reading that is choppy and labored, not smooth or fluent

Oral reading that lacks inflection and sounds like the reading of a foreign language

A reliance on context to discern the meaning of what is read

A better ability to understand words in context than to read isolated single words

Disproportionately poor performance on multiple­choice tests

The inability to finish tests on time

The substitution of words with the same meaning for words in the text he can't pronounce, such as car for automobile

Disastrous spelling, with words not resembling true spelling; some spellings may be missed by spell check

Trouble reading mathematics word problems

Reading that is very slow and tiring

Homework that never seems to end, or with parents often recruited as readers

Messy handwriting despite what may be an excellent facility at word processing­­nimble fingers

Extreme difficulty learning a foreign language

A lack of enjoyment of reading, and the avoidance of reading books or even a sentence

The avoidance of reading for pleasure, which seems too exhausting

Reading whose accuracy improves over time, though it continues to lack fluency and is laborious

Lowered self­esteem, with pain that is not always visible to others

A history of reading, spelling, and foreign language problems in family members

Reproduced with permission from: Shaywitz S. Overcoming Dyslexia: A New and Complete Science­Based Program for Reading Problems at Any Level. Copyright © 2003 by Sally Shaywitz, M.D. Used with permission of Alfred A. Knopf, a https://www.uptodate.com/contents/specific­learning­disabilities­in­children­role­of­the­primary­care­provider/print 26/34 5/23/2017 Specific learning disabilities in children: Role of the primary care provider ­ UpToDate division of Random House, Inc. For on­line information about other Random House, Inc. books and authors, see the Internet Web site at www.randomhouse.com.

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Clues to dyslexia in young adults and adults

Problems in speaking

Persistence of earlier oral language difficulties

The mispronunciation of the names of people and places, and tripping over parts of words

Difficulty remembering names of people and places and the confusion of names that sound alike

A struggle to retrieve words: "It was on the tip of my tongue"

Lack of glibness, especially if put on the spot

Spoken vocabulary that is smaller than listening vocabulary, and hesitation to say aloud words that might be mispronounced

Problems in reading

A childhood history of reading and spelling difficulties

Word reading becomes more accurate over time but continues to require great effort

Lack of fluency

Embarrassment caused by oral reading: the avoidance of Bible study groups, reading at Passover seders, or delivering a written speech

Trouble reading and pronouncing uncommon, strange, or unique words such as people's names, street or location names, food dishes on a menu (often resorting to asking the waiter about the special of the day or resorting to saying, "I'll have what he's having," to avoid the embarrassment of not being able to read the menu)

Persistent reading problems

The substitution of made­up words during reading for words that cannot be pronounced­­for example, metropolitan becomes mitan­­and a failure to recognize the word metropolitan when it is seen again or heard in a lecture the next day

Extreme fatigue from reading

Slow reading of most materials: books, manuals, subtitles in foreign films

Penalized by multiple­choice tests

Unusually long hours spent reading school­ or work­related materials

Frequent sacrifice of social life for studying

A preference for books with figures, charts, or graphics

A preference for books with fewer words per page or with lots of white showing on a page

Disinclination to read for pleasure

Spelling that remains disastrous and a preference for less complicated words in writing that are easier to spell

Particularly poor performance on rote clerical task

Reproduced with permission from: Shaywitz S. Overcoming Dyslexia: A New and Complete Science­Based Program for Reading Problems at Any Level. Copyright © 2003 by Sally Shaywitz, M.D. Used with permission of Alfred A. Knopf, a division of Random House, Inc. For on­line information about other Random House, Inc. books and authors, see the Internet Web site at www.randomhouse.com.

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Overview of Section 504 of the Rehabilitation Act

What is Section 504?

Section 504 of the Rehabilitation Act of 1973 is a national law that protects qualified individuals from discrimination based on their disability. The nondiscrimination requirements of the law apply to employers and organizations that receive financial assistance from any federal department or agency, including the United States Department of Health and Human Services (DHHS). These organizations and employers include many hospitals, nursing homes, mental health centers, and human service programs.

Section 504 forbids organizations and employers from excluding or denying individuals with disabilities an equal opportunity to receive program benefits and services. It defines the rights of individuals with disabilities to participate in, and have access to, program benefits and services.

Who is protected from discrimination?

Section 504 protects qualified individuals with disabilities. Under this law, individuals with disabilities are defined as persons with a physical or mental impairment which substantially limits one or more major life activities. People who have a history of, or who are regarded as having, a physical or mental impairment that substantially limits one or more major life activities are also covered. Major life activities include caring for oneself, walking, seeing, hearing, speaking, breathing, working, performing manual tasks, and learning. Some examples of impairments which may substantially limit major life activities, even with the help of medication or aids/devices, are: AIDS, alcoholism, blindness or visual impairment, cancer, deafness or hearing impairment, diabetes, drug addiction, heart disease, and mental illness. In addition to meeting the above definition, for purposes of receiving services, education, or training, qualified individuals with disabilities are persons who meet normal and essential eligibility requirements.

For purposes of employment, qualified individuals with disabilities are persons who, with reasonable accommodation, can perform the essential functions of the job for which they have applied or have been hired to perform. (Complaints alleging employment discrimination on the basis of disability against a single individual will be referred to the United States Equal Employment Opportunity Commission for processing.)

Reasonable accommodation means an employer is required to take reasonable steps to accommodate your disability unless it would cause the employer undue hardship.

Prohibited discriminatory acts in health care and human services settings

Section 504 prohibitions against discrimination apply to service availability, accessibility, delivery, employment, and the administrative activities and responsibilities of organizations receiving federal financial assistance. A recipient of federal financial assistance may not, on the basis of disability:

Deny qualified individuals the opportunity to participate in or benefit from federally funded programs, services, or other benefits. Deny access to programs, services, benefits or opportunities to participate as a result of physical barriers. Deny employment opportunities, including hiring, promotion, training, and fringe benefits, for which they are otherwise entitled or qualified. These and other prohibitions against discrimination based on disability can be found in the DHHS Section 504 regulation at 45 CFR Part 84.

For information on how to file a complaint of discrimination or to obtain information of a civil rights nature, please contact us. Office of Civil Rights employees will make every effort to provide prompt service.

Hotlines: 1­800­368­1019 (Voice) 1­800­537­7697 (TDD)

E­mail: [email protected] Web site: http://www.hhs.gov/ocr

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Strategies to enhance resilience and success in children and adolescents with learning disabilities

Exhibit belief in the child's or adolescent's positive attributes

Find words to describe the attributes of the child or adolescent in positive terms

Identify the child's or adolescent's areas of strength and highlight those skills and their contribution to the family's well­being [1]

Accept the unique pattern of the child's or adolescent's strengths and weaknesses

Emphasize effort rather than achievement

Emphasize the value of education

Establish realistic expectations

Praise success and avoid frustration by matching tasks to the child's or adolescent's level of functioning and interests

Align expectations with child's or adolescent's capabilities, considering personal temperament, moral development, and learning style

Communicate realistic expectations and celebrate effort to achieve a skill or goal

Prepare the child or adolescent for new situations to ensure success

Match expectations to child's or adolescent's temperament

Teach socially acceptable methods of requesting information or stating personal desires

Recognize the individual's unique learning style

Monitor books that the child chooses to read independently to prevent undue frustration; helping the child to choose books at his or her "independent" reading level (99 percent accuracy); reading the age­appropriate books that are beyond the child's independent reading level aloud to the child [2]

Use many senses to assist a child to learn information

Provide the child or adolescent with the opportunity to assume responsibility

Encourage independence (in situations where the child or adolescent is likely to be successful) to enhance self­esteem

Give the individual household and personal tasks that are within the ability of the individual

Permit the individual to experience the management of money, considering age and ability to self­regulate

Assist children and adolescents to manage their modes of transportation independently, as appropriate for age and level of self­regulation

Encourage decision­making

Improve social skills and provide opportunities for successful social interaction

Keep children abreast of current events

Involve children in community service

Encourage activities of interest rather than age outside of home and school

Avoid intensive competition

Be consistent about rules and limits

Keep rules to a minimum

Seek to educate and negotiate rather than dictate

Apply logical consequences

Use positive reinforcement

Use rewards only when needed

Reward effort and initiative, as well as achievement

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Permit parents to provide support for each other as they navigate educational decisions, school communication, advocate for their child, and make social decisions

Use a team approach to parenting, including shared responsibility for decision­making and child management[2]

Give siblings adequate time and attention

Listen to feelings

Look for outside support when necessary Parent support groups Individual, marriage, and family counseling

Adapted from: Smith C, Strick L. Strategies for Promoting Personal Success. In: Learning Disabilities: A to Z: A parent's complete guide to learning disabilities from preschool to adulthood, The Free Press, a division of Simon & Schuster, Inc., New York 1997. p.257. 1. Lock RH, Janas M. Build Resiliency. Intervention in School & Clinic 2002; 38:117. 2. Lerner J. Learning Disabilities: Theories, Diagnosis, and Teaching Strategies, Houghton Mifflin Company, Boston 2000.

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Resources for health care providers, patients, and families of children with learning disabilities*

Resource Description

American Academy of Pediatrics Council on School Provides technical assistance and resources to clinicians with Health an interest in school health www2.aap.org/sections/schoolhealth

Council for Exceptional Children Provides advocacy and professional development and www.cec.sped.org resources

Early Childhood Technical Assistance Center Provides information and summaries of IDEA and the 2004 ectacenter.org/idea/idea.asp amendments to IDEA

Families and Advocates Partnership for Education Links to information about IDEA www.fape.org

Family Voices Provides information and advocacy for children with special www.familyvoices.org needs

International Dyslexia Association Provides comprehensive information, referral services, and dyslexiaida.org advocacy

LD OnLine Provides information and advice about LD and attention deficit www.ldonline.org hyperactivity disorder for parents, teachers, and other professionals

LD Navigator Provides practical information about LD for health care ldnavigator.ncld.org professionals

The Learning Disabilities Association of America Provides advocacy www.ldaamerica.org

Medical Home Portal Provides information for parents and families and www.medicalhomeportal.org professionals (choose appropriate tab and select "Education & Schools" from the menu)

National Center for Learning Disabilities (NCLD) Provides information to parents, professionals, and www.ncld.org individuals with LD; promotes research and programs; and advocates for policies to strengthen educational rights and opportunities

Office of Special Education and Rehabilitative Services Provides leadership and financial support to support children www2.ed.gov/about/offices/list/osers/osep/index.html with disabilities

Parent Advocacy Coalition for Educational Rights Provides assistance to families, workshops, and information www.pacer.org for parents and professionals

Parent Technical Assistance Center Network Works to fortify partnerships between parent centers and www.parentcenterhub.org/ptacs education systems at local, state, and national levels

IDEA: Individuals with Disabilities Education Act; LD: learning disability. * In this table, "learning disability" refers to a heterogeneous group of disorders characterized by the unexpected failure of an individual to acquire, retrieve, and use information competently, rather than intellectual disability (mental retardation).

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Americans with Disabilities Act

Title I of the Americans with Disabilities Act of 1990, which took effect July 26, 1992, prohibits private employers, state and local governments, employment agencies, and labor unions from discriminating against qualified individuals with disabilities in job application procedures; hiring; firing; advancement; compensation; job training; and other terms, conditions, and privileges of employment. An individual with a disability is a person who:

Has a physical or mental impairment that substantially limits one or more major life activities Has a record of such an impairment Is regarded as having such an impairment A qualified employee or applicant with a disability is an individual who, with or without reasonable accommodation, can perform the essential functions of the job in question. Reasonable accommodation may include, but is not limited to:

Making existing facilities used by employees readily accessible to and usable by persons with disabilities Job restructuring Modifying work schedules Reassignment to a vacant position Acquiring or modifying equipment or devices Adjusting modifying examinations, training materials, or policies, and providing qualified readers or interpreters An employer is required to make an accommodation to the known disability of a qualified applicant or employee if it would not impose an "undue hardship" on the operation of the employer's business. Undue hardship is defined as an action requiring significant difficulty or expense when considered in light of factors such as an employer's size, financial resources, and the nature and structure of its operation.

An employer is not required to lower quality or production standards to make an accommodation, nor is an employer obligated to provide personal use items such as glasses or hearing aids.

Medical examinations and inquiries

Employers may not ask job applicants about the existence, nature, or severity of a disability. Applicants may be asked about their ability to perform specific job functions. A job offer may be conditioned on the results of a medical examination but only if the examination is required for all entering employees in similar jobs. Medical examinations of employees must be job related and consistent with the employer's business needs.

Drug and alcohol abuse

Employees and applicants currently engaging in the illegal use of drugs are not covered by the ADA when an employer acts on the basis of such use. Tests for illegal drugs are not subject to the ADA's restrictions on medical examinations. Employers may hold illegal drug users and alcoholics to the same performance standards as other employees.

EEOC enforcement of the ADA

The EEOC issued regulations to enforce the provisions of Title I of the ADA on July 26, 1991. The provisions originally took effect on July 26, 1992 and covered employers with 25 or more employees. On July 26, 1994, the threshold dropped to include employers with 15 or more employees.

ADA: Americans with Disabilities Act; EEOC: U.S. Equal Employment Opportunity Commission.

Americans with Disabilities Act of 1990. Available at: www.ada.gov/pubs/ada.htm (Accessed on April 14, 2015).

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Contributor Disclosures

L Erik von Hahn, MD Nothing to disclose Carolyn Bridgemohan, MD Nothing to disclose Marc C Patterson, MD, FRACP Grant/Research/Clinical Trial Support: Vtesse [Niemann­Pick C (Cyclodextrin)]. Consultant/Advisory Boards: Actelion [Niemann­Pick C (Miglustat)]; Agios [CGD]; Alexion [General lysosomal diseases, lysosomal acid lipase deficiency (Sebelipase alfa)]; Amicus [Fabry, Gaucher, Pompe (Migalastat)]; Novartis [MS]; Shire [MLD]. Other Financial Interest: Sage [Honorarium as Editor­in­Chief of Journal of Child Neurology and Child Neurology Open]. Mary M Torchia, MD Nothing to disclose

Contributor disclosures are reviewed for conflicts of interest by the editorial group. When found, these are addressed by vetting through a multi­level review process, and through requirements for references to be provided to support the content. Appropriately referenced content is required of all authors and must conform to UpToDate standards of evidence.

Conflict of interest policy

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