10
Learning problems
Chapter map
School attendance and education is second only to the family in influencing a child’s life. Doing well at school is part of a child’s overall health, and we should try to prevent illness disrupting a child’s social and academic education as much as possible. For some children who get little support or encouragement at home, school may be a place of sympathy and understanding.
It is therefore of great importance that:
- Children are in the best physical, mental and emotional health to benefit from their education.
- Schools encourage learning in a broad perspective, supporting each child in achieving their individual potential.
- Children leave school self-confident, healthy and self-directed in their aspirations.
10.1 Medical causes of educational difficulty
10.1.3 Intellectual (learning) disability
10.2 Early diagnosis and assessment
10.3.4 Disorders of speech and language
10.4.2 Developmental coordination disorder
10.5 Special educational needs
10.5.1 Statement of special educational needs
10.1 Medical causes of educational difficulty
In the UK, over 90% of children are educated in the public sector, while state and private schools run side by side. Around 20% of children will have special educational needs at some stage, that vary from minor to major. Most will simply need some extra support within mainstream schools. Some, if the problems are more severe, will receive education in a special school designed, staffed and organized to meet their needs.
The main medical problems which can affect children’s education may be considered in groups, and not infrequently children have problems in more than one group.
10.1.1 Physical – motor
Disorders such as cerebral palsy (Section 17.8), muscular dystrophy and severe congenital abnormalities clearly are very important. Other children have minor motor problems such as clumsiness, or difficulty with more complex tasks (dyspraxia), which can be difficult to recognize. Motor problems may make games, stairs, corridors or getting round the school difficult. Wheelchair users cannot negotiate stairs and need wide toilets. Problems of manipulation may prevent the use of normal writing implements: special pens or a computer may be needed.
10.1.2 Physical – sensory
Impaired vision or hearing present obvious barriers to education. If they are severe, and especially if they are combined (the deaf/blind), special equipment and specially trained teachers are necessary. Early recognition and support of children with mild or severe problems is very important and changes a child’s prognosis.
10.1.3 Intellectual (learning) disability
Intelligence is difficult to define, but it has to do with understanding, reasoning and the association of ideas. It is not closely related to memory or creativity, nor has it much to do with sociability, which may be conspicuous by its absence in the super-intelligent.
Intelligence can be measured by a wide variety of ‘intelligence tests’, the results of which are often expressed as intelligence quotients (IQ). Quotients are calculated as the child’s functioning age as a percentage of their chronological age. A global and detailed assessment of a child’s ability is more helpful than a single quotient. This provides a more comprehensive picture of the particular strengths and weaknesses of the individual child, and hence an indication of the particular kinds of help needed.
Most children with intellectual disability are between 2 and 3 SDs below the mean of the normal distribution curve, and often there is no obvious cause, although they may have parents of low IQ. Children with skills >3.5 SD below the mean are more likely to have a cause for their leaning problems, congenital or acquired.
Children with moderate learning difficulties are usually best served by the provision of extra help in the classroom (usually non-teaching aides) in mainstream schools. More severe impairment needs the facilities and specially trained staff of a special school.
10.1.4 Emotional
Emotional problems often reflect social problems at home. A few children are difficult to motivate, in sharp contrast to the normally insatiable appetite for information in young children. Others are hyperactive, aggressive, destructive or antisocial. Not only are they difficult to teach, but they disrupt the classroom and make the teacher’s task very difficult.
10.1.5 Communication
Communication is receptive and expressive. Receptive problems are usually due to deafness or associated with learning difficulties. Some children with dysarthria and cerebral palsy, or other motor disorders, may understand but not be able to express. There are also a variety of disorders, including autism (Section 11.5.3.1) and dyslexia (see Section 10.4.1) which cause severe difficulties. The detailed diagnosis of these problems, and the devising of a suitable educational programme, call for very special skills.
10.1.6 Chronic illness
Chronic illness can interfere with education in a number of ways. Intractable asthma, for example, may result in frequent absences from school and in tiredness, and may result in poor academic progress. Epilepsy may place some restrictions on physical activities. Diabetes and coeliac disease affect meals taken at school. Juvenile arthritis limits physical activities.
10.2 Early diagnosis and assessment
10.2.1 Developmental delay
One of the main reasons for recommending that all young children should undergo regular developmental assessment (Section 9.2) is to detect significant delay as early as possible. Another reason is to reassure parents who are unnecessarily anxious about their child. Learning disability is likely to present as delayed development, unless there are physical features (e.g. Down syndrome, microcephaly) which permit early prediction of difficulty. Although all children with learning disability are late developers, the reverse is not necessarily true.
PRACTICE POINT10.2.2 Assessment
Faced with a child who is reported or found to be late smiling, sitting, walking or talking, a full paediatric history is essential:
- Was the baby very preterm? Has she spent long periods in hospital? Has she had proper care at home?
- Is she delayed in all developmental areas or only in selected aspects? Most children with more severe learning disability have delay in all areas, although gross motor development is often better than social and language development.
- Can a specific cause be found for a specific delay? If speech is delayed, is she deaf? If walking is delayed, does he have muscular dystrophy?
- A single assessment, especially if the child is having an ‘off’ day, is usually inadequate for decision making. Re-examination, to assess progress is often helpful.
- Progressive (degenerative) brain disease leads to loss of previously achieved skills. It is rare and important.
- Chromosome abnormalities (30%), e.g. Down syndrome.
- Metabolic disease (under 5%), usually recessively inherited, e.g. galactosaemia, phenylketonuria.
- Neurocutaneous syndromes (under 5%), often dominantly inherited, e.g. tuberous sclerosis, neurofibromatosis.
- Other genetic causes, e.g. X-linked intellectual disability and some cases of microcephaly.
- Idiopathic – the cause cannot be identified.
- Prenatal, e.g. alcohol, infections (rubella, CMV).
- Perinatal, e.g. prematurity, haemorrhage, hypoxia, meningitis, septicaemia, hyperbilirubinaemia, hypoglycaemia.
- Postnatal, e.g. trauma, infection.
10.2.3 Diagnosis
There are three stages in the diagnosis of a ‘late developer’:
- Is the delay significant? Or does the child fall within the range of normal?
- What is the nature of the problem – learning disability, deafness, social deprivation?
- What is the cause? This may be relevant to treatment and genetic counselling. Clinical assessment may indicate investigation (biochemical screening of blood and urine for metabolic disorders; serological tests for prenatal infections; neuroradiological studies).
10.2.4 Management
Prevention is unfortunately often not possible. Genetic counselling may prevent recurrence of genetic disorders; rubella immunization should be universal; neonates are screened for phenylketonuria and hypothyroidism (Section 27.3.3); and, clearly, avoidance of acquired damage should help.
Support of the child and family is the mainstay of management. For most children with severe disability there is no cure. With modern health care, life expectancy is often normal. These circumstances place great strains on families. Children with disabilities can take up all the time and energies of both parents, leading to physical exhaustion (especially as the children get older and heavier), neglect of siblings and the breakdown of marriages. The problems faced by single parents and families with socioeconomic problems are multiplied.
The principle is to help the child to develop to his full potential, however little this may be, and to offer all possible help and support to the family. Many children with learning disability have additional problems such as cerebral palsy, epilepsy or deafness. Multidisciplinary assessment is therefore essential before any treatment programme is drawn up. Although the health services have an important role, it is the social and educational services which have the chief responsibilities for helping children with learning disability. Many systems have been devised for encouraging maximal progress. Some are variations on traditional methods, which have been properly assessed. Some, which unfortunately attract great media attention, play (to their considerable profit) on the eternal hope of parents that a cure may be found. Doctors must be understanding of parents who decide to try unorthodox methods, and must be prepared to help pick up the pieces if disappointment follows.
Stay updated, free articles. Join our Telegram channel
Full access? Get Clinical Tree
