In February 2021, NCLD’s Senior Advisor, Dr. Sheldon H. Horowitz, and Dr. Marc Lerner, a developmental and behavioral pediatrician, hosted a webinar on the importance of early detection of learning difficulties and attention issues. A recording of the webinar can be found below. Answers to questions submitted for the panelists are included below.
General Questions about Learning Disabilities
Q: What should parents do if they suspect their child has dyslexia?
A: Dyslexia is a clinical word used to describe a specific learning disability in reading, so the obvious “to-do” list for parents should include such steps as:
- Share the reasons (and details) of concern with teachers;
- Request that school personnel conduct an appropriate screening,
- If efforts to intervene are not successful, request (in writing) that a formal evaluation be conducted to determine the precise nature of the problem and identify the most effective program of intervention and support.
Q: Some children struggle with math learning but not reading (that is, until they hit a wall with word problems!). Is the short list of questions enough to identify children with LD in this area?
A: Math is an often-overlooked area when questions and concerns about learning disabilities are raised. Recent studies have confirmed that there is much more overlap (and co-occurrence) between disorders of math and reading (literacy) than initially thought. The LD Checklist is not intended to be diagnostic in any way, so the decision was made to limit the number of detailed characteristics in any domain, including math. As a first quick look at math as a possible area of risk, the LD Checklist should do the trick.
Q: Doesn’t “differential diagnosis” also imply some uncertainty about the presence of one vs. the other? And which is the “primary”?
A: Differential diagnosis in medicine refers to a concern that can stem from multiple causes. A child may struggle in school due to a language learning problem (dyslexia), problems seeing the book, difficulties with focus, and any number of other causes. The job for educators and medical personnel is to identify the specific cause and then develop a program to support growth in learning and success. In the absence of a ‘gold standard’ medical test (one with near 100% accuracy), pediatricians are trained to address the most likely cause of behavioral and learning issues and consider other possibilities if response to treatment is not optimal.
Questions about Early Detection
Q: Can the early detection of learning and attention issues be addressed in public elementary schools?
A: Early recognition of risk for struggle with learning and attention can, and should, be addressed in public schools. And not just through special education and related service providers. Classroom teachers who are skilled observers, can identify patterns of relative strength and weakness, and provide targeted help in ways that help determine whether students are experiencing instructional gaps or possible early signs of a disability
Q: Why is the early detection of learning disabilities difficult to do in public schools?
A: It is true that many schools, unfortunately, wait until a student is struggling before taking a careful, systematic look at where students are in terms of progress in academic and social skill development. This “wait to fail’ approach is often so deeply embedded in school systems that it’s hard to step back and change course. Schools that embed early detection into their work save money, empower teachers, and protect students from experiencing frustration and feelings of anxiety, low self-confidence diminished motivation.
Q: Why does most identification of learning disabilities or attention issues happen in or after grade 3?
A: There is no single reason to why things shift around this time, but for many children, part of the reason may have to do with reading. The vast majority of children who have learning disabilities struggle in the area of literacy, and it is right about this time when their school experience (and teachers expectations) shift from ‘learning to read’ to ‘reading to learn.’ Without having been identified early as needing additional support in reading, the pressure to digest printed materials quickly and accurately, understand what is being read, and convey that knowledge into written narrative quickly becomes more than a little daunting.
Q: What can schools do to detect learning struggles earlier? Why are they not?
A: There is an expression in the business world that says “an informed consumer is the best customer.” The same could be said of teachers and parents. Having accurate information about what to expect of children across different subject and skill areas and monitoring performance over time (including how they respond to intervention) are sure ways to capture behaviors that point to potential risk for LD. A school wide commitment to communication among faculty and with students, their parents, and their expert care providers (e.g., pediatricians) takes lots of planning and hard work. But it’s definitely worth the effort.
Q: If a school suggests to a parent that their child may have a LD, there is always the concern that the child may not have a LD, and schools do not want to worry parents. What can be done about that?
A: Let’s answer this question with an extreme example. Would a school withhold concern from a parent if they thought a student had a broken bone, a problem breathing or trouble with hearing or vision? Not likely. So why would they worry about sharing concern about a student who, for unexplained reasons, is struggling to keep up with their peers, despite good effort and motivation? In fact, when students with LD finally have a ‘name’ and explanation for why they are struggling, they often express relief and give themselves permission to access the specific types of specialized instruction and support needed to excel in school. That said, parents are sometimes the ones who take longer to adjust, often admitting to feelings of shame and embarrassment, and not knowing how to overcome the stigma they associate with their child having a disorder.
Q: It is very expensive to give a child a full psycho-educational evaluation in public schools. Do you have suggestions to make it more affordable for public schools that are already on a limited budget?
A: This is a great question to which there is no simple answer. But common sense would suggest that a “full” evaluation should provide the information needed to make an informed decision about whether a child meets the criteria for special education classification and what specific types of services and supports are needed to help the child make progress. There is, for example, no requirement that a comprehensive evaluation delve deeply into the area of math if their math grades are good, they are progressing nicely in mastering elements of the curriculum, and they are able to participate in class. Sure, problems with reading math problems or following written instructions might be identified, but by focusing the evaluation on literacy (if that’s the presenting problem), recommendations can easily be made to address reading challenges during math learning. Must a comprehensive evaluation include a full battery of psychological testing? The answer is no, but that’s a much larger discussion for another webinar!
Questions on Early Detection in a Medical Setting
Q: Where can parents go to see what the American Academy of Pediatrics (AAP) should expect their members to include when they see/test children?
Q: How can service providers enhance the much-needed communication between parents and medical staff? We see so much and are afraid that parents aren't communicating to medical professionals.
A: 1. Develop your child’s personal story beforehand including these elements:
- A written timeline of signs and symptoms
- A note of when you or someone else first noticed that something was different or unusual
- A note about what specifically concerned you
- Any relevant photographs or videos
- Practice two-way communication.
- They should ask you about your questions. Write these down in advance and don’t be timid about asking.
- Remember that doctors and nurses are scientists who like facts.
- Clinicians are helped when you provide key factual details. Before your appointment, take some time to draw up some key facts, such as:
- Information about other previous diagnostic tests and their results
- Information about previous medication trials
- A detailed medical history, which includes a mother’s pregnancy, labor and delivery history; other illnesses; current and past medications; and recollection of similar symptoms in other family members.
- Visual communication is also key for providers.
- In addition to hearing from you, the clinician will want to observe your child to see for themselves what’s happening. This can include a physical examination.
- Engage in strategies that help make communication even better.
- It is OK to bring along another family member or an advocate and prepare a list of questions ahead of time with specific requests about further diagnostic studies.
You can even bring your own research to the clinic visit about diagnosis and management strategies. Here’s an example.
Q: We have been trying to engage and educate pediatricians in our state to increase early identification and provide resources for parents on services and supports for their children. What can you recommend we do to better reach pediatricians? Are there medical journal papers or pediatric society recommendations that we should be sharing with them?
A: A good contact is the AAP Chapter in your state. The website for the chapter includes a list officers, the executive director and others who will be interested in these issues and be able to meet the educational needs of their membership, often through professional continuing education. You can review policy statements and practice guidelines on the AAP website that are published to inform and guide pediatric practice as well.
Questions on the Role of the Medical Provider
Q: Is it okay for pediatricians to give strong medications to young children for ADHD without talking to a counselor?
A: The AAP provides guidelines that are based on the best available scientific research to assist clinicians in evaluation and care. In the area of ADHD, this includes guidelines on the optimal approach in sequencing options for treatment, such as the use of behavioral therapy (always recommended first for preschoolers) and other non-medication as well as proven medications.
Q: I often discover children might have a learning disability when I work with them in my role as a specialized instructional support person focused on emotional disturbances. How do I go about getting them help without stepping on the primary care provider’s territory?
A: Children with learning and behavior concerns may present in a variety of medical settings, for example, the child with poor attention who is seen for an injury after an accident impacted by poor focus. Parents can be encouraged to engage the resources of their community via their primary care clinician in their medical home or by information and referral services. These may include ‘Help Me Grow’ programs, 211 referrals and Child Find activities of local school districts. And other parents who know of options can recommend pathways to getting needed services and supports.
Q: Can the AAP exert its influence to change the public schools’ approach to underachieving students from "wait to failure" to early evaluation and interventions?
While the AAP has advocacy activities at the state and national level, each pediatrician can advocate on behalf of their own patients with local learning systems. Sometimes this is done with a letter, and sometimes by referral to private resources that can bring a more complete picture of a child’s strength and challenges to bear in discussions with the local school. We know that many school personnel have been directed to avoid some aspects of referral (for example, for a medical consultation) as it may require payment at the district’s expense. They may also be concerned about the possible negative impact of labeling on a child’s success. Schools increasingly are using an MTSS (Multi-tiered System of Supports) approach to match interventions to the needs of each student (www.pbisrewards.com › blog › what-is-mts). When implemented with fidelity, MTSS can often circumvent the need for evaluation and prevent the wait-to-fail approach from keeping students from receiving just-in-time instruction and intervention.
Other Types of Medical Issues
Q: I am fostering a 9-month infant diagnosed with Neonatal Abstinence Syndrome. Is there a checklist to use for his development?
A: First, thank you for the incredibly important care you are providing. Babies born to mothers who were addicted to opiates, using (abusing) other substances and living lifestyles that place the health of their unborn child at risk need careful monitoring and specialized support. Close communication between pediatric providers and caregivers is essential so that these children have the best chance to overcome early threats across multiple domains for development. Yes, there are checklists that doctors use to assess the signs and severity of withdrawal in infants, but once the child’s medical issues are addressed, the LD Checklist can be a helpful tool for observing progress in key areas such as early language and motor skills development.
Q: How do you suggest the best way to educate parents regarding vision difficulties during classroom tasks?
during classroom tasks?
A: Children should have their eyes examined and vision tested as a part of both health care visits and school screenings. These exams can begin very early now, with physical exams complemented by tools such as photo screeners (a camera that takes images of a child’s undilated eyes). Some features that should lead to updated assessments include:
- If children tend to avoid reading or other close up (near vision) work
- if there is a difference between the vision in the child’s two eyes (during this time of COVID, parents may screen this by having their child cover one eye at time.)
- if a child has previously worn glasses but no longer has them
- if a child sits close to the TV or computer screen, or holds mobile devices, like iPad or books very close to their eyes
- If a child uses their finger to hold their place or help keep track of the line of words when reading
- if grades begin to drop (which may be a sign that a child is not seeing things clearly enough to learn)
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