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PEDIATRICS

Vol. 58 No. 3 September

1976

409

understand 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 educators

to 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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410 LEARNING DISABILITIES

as to why the child with normal or better

intelli-gence cannot keep up with his peers in school

work.

The author specializes in neurodevelopmental

pediatrics and does private practice within the

framework of a model designed to provide

diag-nosis and treatment for learning disabled

chil-dren. Over the years, a diagnostic screening

evaluation has evolved. This evaluation, which

can be performed by a pediatrician in his office,

provides the guidelines for immediate and

long-term intervention.

ASSEMBLING THE DATA BASE

An accurate and comprehensive data base must

be assembled before the child is seen. Parents and

teachers are asked to fill out questionnaires to

determine whether there are correlates between

the medical background, behavior, and school

performance.

In the office, the assistant measures the child

(height, weight, chest and head circumference)

and tests vision, color discrimination, and hearing.

The pediatrician then performs the standard

pediatric-neurological examination within which

he interweaves an age-specific

neurodevebop-mental assessment. While the physician and

parents together review the history, the aide

screens for psychoeducational inefficiencies.

Neurodevelopmental Assessment

To avoid bias the examination is done without

discussing history. The parents are present to

make them aware of the child’s performance in a

test situation. The assessment is made up of items

derived from standardized data which have been

validated in normal populations and have been

shown to relate to academic performance.2t

Items of a psycholinguistic or visual perceptual

motor nature are evaluated in the

psychoeduca-tional screening procedure, but many can be

performed in conjunction with the neurodevelop-mental assessment.

Psychoeducational Screening Evaluation

Various items from standardized tests are used

to provide glimpses into intellectual functioning

as well as language, perceptual, and academic

#{176}Copies of the questionnaire may be obtained from the author.

t

Copies of the neurodevelopmental assessment and the psychoeducational screening evaluation may be obtained from the author.

performance. Careful attention is paid to an

appraisal of the patient’s overall behavior,

espe-ciably attention span, and to the quality of his

work habits.

Parent Interviews

When the examination and testing is finalized,

the parents and physician complete the data base

by probing more deeply into school and family

factors. Then the results of the examination are discussed. Learning-disabled children often are

found to have combinations of adiadokokinesis,

poor bilateral patterned skills, sensory intake,

spatial relationships, and intersensory processing

difficulties, as well as letter reversals or omissions

in writing, and auditory, perceptual, and related

disorders in reading or spelling. The parent and

teacher complaints are usually of inattentiveness

or overactive behavior, language delay, motor

clumsiness, or difficulty in comprehension. The

pediatrician discusses the relationship of the

complaints to the findings and formulates plans to

develop means of dealing with each problem.

He tries to change the parents’ perception of

the child as “spoiled” or “lazy” to “inefficient” or

“frustrated,” and he helps to desensitize family

and school tensions by an immediate family and

school management program. He may suggest combinations of behavior modification, parent or

teacher supportive help, or a diagnostic trial of

medication if it appears indicated. At this point,

consultative services are required. Minimally, a

psychological evaluation including personality

factors and a special education survey is required. These evaluators may bring out the need for

further visual perceptual, language, or psychiatric

appraisal.

While awaiting results the pediatrician shows

his willingness to assume an advocacy role by

routing a report to the school and making certain

that the visit does not end with a long list of

referrals without plans for reevaluation and

continuity of care.

MANAGEMENT

When the results of testing are finalized, the

child is reexamined to recheck suspicious

findings, and the parents and pediatrician review the past month’s performance. The pediatrician

discloses the results of the full assessment and

presents recommendations which likely relate to

curriculum or class readjustment, supportive help

in school subjects, and child and family

counsel-ing.

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PEDIATRICS

FOR THE CLINICIAN

411

If the diagnostic trial of medication has been

successful, or if other evaluators point out a need,

it is recommended. The criteria for the use of

medication are:

(

1) Anticonvulsants: the presence of overt

seizures; a history of behavior suggesting, or

psychological tests pointing to a seizure disorder,

especially when coupled with an abnormal EEC

pattern.

The standard anticonvulsant medications are

recommended with an awareness that

phenobar-bital may produce a paradoxical behavior

activat-ing effect.

(2) Psychostimulants: Attention span during

tasks involving visual and auditory skills reduced

to less than the 25th percentile for the child’s age;

the presence of choreiform movements; EEC

evidence of depleted alpha wave activity and/or

asymmetric interhemispheric activity; a history of

infantile or pre-school hyperactivity and

observ-able behavior for’

Dextroamphetamine (Dexedrine Spansule) is

tried first using a single 5-mg spansule at

break-fast for one week, and then a 10-mg spansule if no

improvement. The teacher is not informed of its

use in order to obtain an objective view of school

behavior and performance. If this drug is

ineffec-tive, levoamphetamine (Benzedrine) in a single

10-mg spansule is tried. Methylphenidate

(Rita-lin) in a 5- or 10-mg dose morning and noon may

be substituted for dextroamphetamine if the side

effects are undesirable. When this medication

should be effective and is not, the addition of an

appropriate anticonvulsant medication may be

helpful if the EEC suggests a convulsive pattern.

The smallest effective dose is used and

medica-tion-free periods during long holidays are

suggested.

Teacher and parent behavior rating scales are

used regularly to evaluate progress. The need for

medication is reevaluated at the start of each new

school year.

Tranquilizers are used based upon

recommen-dations from projective tests or from psychiatrists.

Again, the standard tranquilizers in appropriate

doses may be used.

When parents object to medication and the

results of behavior modification and parent

mo-deling are inconclusive, then family counseling is

suggested. This modality is often useful in a

complicated case.

CONCLUSIONS AND SUMMARY

The pediatrician has an important contributing

role in the problems associated with learning

disabilities, but often does not know how to

capitalize on his strengths. He knows the child

and family intimately, and parents will listen to

him for guidance and direction. He can rule out

disease and point to areas of inefficient

develop-ment which contribute to the frustration of both

child and teachers. He can provide a

comprehen-sive assessment under his supervision. He can

offer specifics in management, and he can be an

advocate by offering to provide guidance and

direction. With the physician as the advocate,

parents will come away with the feeling that

someone cares what happens, and that the

pedia-trician, knowing the local scholastic, political,

and legislative situation, can guide them more

directly to obtain the proper help for their

learning-disabled child.

REFERENCES

1. Lerner JW: Children With Learning Disabilities. Boston, Houghton Miflin Co, 1971.

2. Denhoff E, Siqueland ML, Komich MP, Hainsworth PK: Developmental and predictive characteristics of items from the meeting street school screening test. Dev Med Child Neurol 10:220, 1968.

3. Frankenburg WK, Goldstein A, Camp BW: The revised Denver developmental screening test: Its accuracy as a screening instrument. J Pediatr 79:988, 1971. 4. Denhoff E, Hainsworth PK, Hainsworth ML: The child

at risk for learning disorder. Clin Pediatr 2:164,

1972.

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1976;58;409

Pediatrics

Eric Denhoff

Learning Disabilities: An Office Approach

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1976;58;409

Pediatrics

Eric Denhoff

Learning Disabilities: An Office Approach

http://pediatrics.aappublications.org/content/58/3/409

the World Wide Web at:

The online version of this article, along with updated information and services, is located on

American Academy of Pediatrics. All rights reserved. Print ISSN: 1073-0397.

American Academy of Pediatrics, 345 Park Avenue, Itasca, Illinois, 60143. Copyright © 1976 by the

been published continuously since 1948. Pediatrics is owned, published, and trademarked by the

Pediatrics is the official journal of the American Academy of Pediatrics. A monthly publication, it has

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