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407
may be in great difficulties with his psychologicalcolleagues as to how to advise the school to proceed. The correlations between findings by
psychologists and physicians, though significant,
are not one to one; that is to say, even a child with
gross neurological problems such as cerebral palsy
will not necessarily have a learning problem. I have seen children with severe perceptuomotor problems of a degree which seemed to me to be clear evidence of brain damage and who, I predicted, would have gross reading difficulties, only to find them reading at a superior level within a year. This is not to say that there is not a relationship between neurodevebopmentab
find-ings and subsequent school performance: there is, and the doctor should watch these children very carefully at regular intervals and be prepared to intervene with help as soon as it becomes clear
that the particular child is one whose neurodevel-opmental status is going to make his functioning in school difficult.
Methods of help vary from country to country, and indeed from school to school, and in the child’s best interests the doctor and his psycholog-ical colleagues will make the best use of those pairs of hands available. In my own experience medication has little to offer in the way of help either to the children who present primarily as
having learning difficulties, or those whose behavior is the outstanding problem. Virtually no children in normal schools should, I believe, be on drug treatment, though a number in special schools may be helped by it.
REFERENCES
1. Bax MCO, Whitmore K: Neurodevelopmental screening
in the school-entrant medical examination. Lancet 2:368, 1973.
2. Donoghue EC, Shakespeare RA: The reliability of
pediatric case-history milestones. Dev Med Child Neurol 9:64, 1967.
3. Rutter M, Tizard J,Whitmore K: Education, Health and
Behaviour. London, Longmans/Green, 1970.
4. Sheridan D: Vision screening for very young or
handi-capped children in aspects of developmental and
paediatric ophthalmology. Heinemann/Lippincott, 1969.
5. Venables WA: The incidence of squint in minimally
handicapped children. Br Orthopaediatr J 24:53,
1967.
6. Holt KS: The Assessment of Cerebral Palsy. London,
Lloyd/Luke, 1965.
7. Mittler P: The Child with Delayed Speech. London,
Heinemann/Lippincott, 1970.
8. Berges T, Lezine I: The imitation of gestures: A
tech-nique for study of the body schema and praxis of
children three to six years of age. Clin Dev Med 1965, No. 18.
Evaluation
of the
Child
With
a Learning
Disorder
Gwendolyn R. Hogan, M.D., and Nell J. Ryan, M.D.
From the Departments of Pediatrics and Neurology, University of Mississippi Medical Center, Jackson
In order to appreciate our approach to the evaluation of a child with a learning disorder it is
necessary to provide some background material. The total population of the state of Mississippi consists of 2.2 million people of which 900,000
did not complete high school and 400,000 did not complete grade school. There are no publicly financed kindergartens and no compulsory school attendance laws in this state. Eighty-eight percent of the children who attend school are,
however, educated in the public school system. The state is divided into 150 separate school districts and 1,140 special education teachers are provided for the entire state. Of these special
ADDRESS FOR REPRINTS: (G.R.H.) Department of
Pedi-atrics, University of Mississippi Medical Center, 2500 North State Street, Jackson, Mississippi 39216.
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408 EVALUATION OF LEARNING DISORDER
education teachers, 1,000 are assigned to classes for the mentally retarded and the remaining 140 teachers provide instruction for children with specific learning disorders. In the Jackson Sepa-rate School District which includes the largest metropolitan area in the state there are 27,496 students enrolled in the public school system and of that number 852 students are in special educa-tion classes. Of these 852 students in special education, 644 are classified as educable mentally retarded,
100
are classified as trainable mentally retarded, and 108 are classified as having specific learning disabilities. This figure for children with specific learning disabilities is well below the estimated figure of 15% which has been deter-mined by other surveys.The vast majority of children entering the first grade have been exposed to no structured learn-ing situation. Routine testing for school readiness is not done in the public school system. First-grade students do receive vision and hearing screening tests which are administered by volun-teers through the PTA. It is noteworthy that no child can be tested for school placement without the parents’ consent and that even if it is deter-mined that a child needs to be in a special education class this can not be accomplished without the parents’ approval. It is apparent that the child is already in the public school system
before it is recognized that he has a learning
disability. It, therefore, becomes the responsi-bility of the teacher to identify the children with learning disorders and to initiate the evaluation of these students. The evaluation and ultimate school placement of a child with a learning disorder is accomplished through the public school system. The mechanism for the evaluation has been set up by the Mississippi State legisla-ture. Ten learning resource centers each of which is staffed by a psychologist, special education teacher, and a speech pathologist have been approved and are to be located in the various geographic areas of the state. Three of these centers are functioning at the present time. There are, in addition, 18 regional screening teams. The staff of these teams is similar to that of the learning resources centers but they function primarily to review testing done locally.
Once a child is identified as having a learning
disability, he is referred to the learning resources center for testing and placement or he is tested
locally by a psychologist and/or a speech pathol-ogist. These tests are then referred to the regional screening teams for review and for determination of school placement. Tests routinely administered are the WISC, Bender Visual Performance Cestalt, Fristo-Woodcock Auditory Screen, and
the Wide Range Achievement Test. The educa-tional needs of the mentally retarded children are provided for adequately by the public school
system but the resources for the child with a
specific learning disorder are limited. Speech therapy is available on a limited basis in some areas but the only resource which is generally available is remedial reading.
Of those children seen and evaluated by the pediatric neurology service at the University of Mississippi Medical Center, approximately 25% have school-related problems. It is, however, exceptionally rare that a child is referred for evaluation of a primary learning disorder. The vast majority of these children are referred for evaluation of nonspecific problems. Most referrals are initiated by the school nurse who requests evaluation of the patient because of somatic complaints such as headaches, black-out spells, and seizures. In many instances these children have obvious learning disorders of which school officials are aware but they are sent with no inference that the underlying school problem is in
any way related to the symptomatobogy. Disrup-tive classroom behavior is the most common presenting complaint of those children who are referred by the teachers. Even then, the child is not referred for evaluation of a possible learning disorder but because the teacher feels that the child is “hyperkinetic” and would like him placed on medication.
It is apparent that though we see many
chil-dren with problems directly related to learning disabilities, medical evaluation of a child with a primary learning disorder is not considered by school officials as a necessary part of the evalua-tion. Since we are asked to see these patients for evaluation of organic disease, our evaluation is essentially the same as that for any child referred for a similar complaint. This includes a complete
history with special emphasis on events surround-ing birth, the acquisition of motor skills and/or loss of previously acquired skills, past niedical conditions, and family history. A careful physical examination and a complete neurological exami-nation are then carried out. The neurological examination includes visual and auditory screen-ing and a fairly comprehensive mental status examination. The child is tested for reading proficiency with the use of standard grade-level texts and with flash cards. The child is asked to copy designs, to trace figures and perform the Coodenough-Harris Draw-A-Person test. Hand-writing is examined and the child is asked to copy key words, letters, numbers, and to work simple arithmetic problems. Language is evaluated by the child’s ability to follow commands and to
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PEDIATRICS
Vol. 58 No. 3 September
1976
409understand spoken and written words. Other diagnostic studies such as EEGs, skull X-ray films, amino acid screen, and cytogenetics are done on a selective basis and only if deemed necessary by
history and neurological examination. If no organic cause for the child’s somatic complaint is found and it is obvious that, for example, the child who is complaining of headaches is in the sixth grade but cannot read at the second-grade level, he is referred back to the public school system for testing for proper school placement and remedial reading. Most of the children who are referred as “hyperkinetic” are in reality mentally retarded and their activity is commensurate with their
mental age.
Our approach to the evaluation of a child with a learning disorder is a conservative one and is based on the conditions prevalent in this state. The educational level of the lower socioeconomic group in the state is generally low and the slow learner is well accepted. There is apathy among the parents and the child is in no way motivated in the home as evidenced by the fact that 43% of the population of Hinds County, which is 224,100, did not complete high school.
It would, of course, be ideal for each child with a learning disorder to have a complete medical and neurological evaluation. In this state such an evaluation is impossible first because of the finan-cial burden it would place on the mid- and lower-socioeconomic groups and second because of the
unavailability of medical and ancillary personnel. There is one pediatric neurologist for the entire state and approximately 100 practicing pediatri-cians who, for the most part, are concentrated in the urban areas. We feel that under the circum-stances prevalent in this state that the child with a learning problem is best evaluated through the mechanism set up by the public school system and that medical evaluation be utilized only when “organic problems” are felt to contribute to the child’s disability. The major difficulty with the present system in this state is the failure of early identification of the child with learning problems. The teacher cannot be expected to achieve this in
a classroom setting. She can, of course, identify
the child with obvious problems but the child with specific learning disabilities is easily missed.
At
the present time there is a concerted effort being made by concerned parents and educatorsto provide publicly financed kindergartens and to
establish compulsory school attendance laws in this state. If publicly financed kindergartens become a reality, this would be the ideal place for routine school readiness testing and the early identification of children with learning
disor-ders.
ACKNOWLEDGMENT
We would like to acknowledge the assistance given by the Mississippi State Board of Education and the Jackson Sepa-rate School District personnel.
Learning
Disabilities:
An Office
Approach
Eric Denhoff, M.D.
From the Governor Medical Center and Brown University Section on Reproductive and Developmental
Medicine, Providence, Rhode Island
Specialists in the arena of learning disabilities must interact closely as a team to develop
mean-ingful comprehensive programs for school-failing children.’ Since school related difficulties are often problems of growth and development, the pediatrician could play an important role on this team. However, he often excludes himself by limiting his examination to a search for organic pathology, without paying sufficient attention to the numerous other factors which can produce
“developmental overload.” Yet, with some addi-tional training, the pediatrician can make a signif-icant contribution to both diagnosis and manage-ment by clarifying developmentally based reasons
ADDRESS FOR REPRINTS: Governor Medical Center, 293
Governor Street, Providence, Rhode Island 02906.
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1976;58;407
Pediatrics
Gwendolyn R. Hogan and Nell J. Ryan
Evaluation of the Child With a Learning Disorder
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