Evaluating and caring for children with a suspected learning disorder in community practice

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Specific learning disorders (SLDs) were previously referred to as ‘learning disabilities’, and are now better understood as persistent challenges that can impact acquisition, organization, retention, understanding, or use of verbal or nonverbal information despite intervention^[1]-[3]. SLDs affect 5% to 10% of school-age children in Canada^[4]. Early identification and intervention help to optimize academic outcomes, self-esteem, and mental health^[3]. SLDs are caused by impairment in one or more neurocognitive processes related to perceiving, thinking, remembering, or learning^[2][3]. They characteristically affect a specific domain of academic function, such as reading fluency and comprehension, written expression, or mathematical computation. Terms such as ‘dyslexia’, ‘dyscalculia’, and ‘dysgraphia’ are used to convey specific patterns of learning impairment.

Children with an SLD may present to their health care provider (HCP) with behaviour issues or mental health symptoms. ‘Red flags’ for SLD can include school avoidance, mood disorder symptoms, specific anxiety about attending school, or a significant disparity between effort put into schoolwork and objective academic achievement^[4].

Children and adolescents with an SLD are also at greater risk for having a co-morbid developmental or neurological disorder such as autism spectrum disorder (ASD), attention-deficit hyperactivity disorder (ADHD), oppositional defiant disorder (ODD), anxiety disorder^[5], developmental coordination disorder, epilepsy, or cerebral palsy^[6][7].

SLD assessment and diagnosis

SLD is a clinical diagnosis, usually made by a psychologist via a psychoeducational assessment, based on a review of school and health records, a detailed history, and standardized testing to determine whether a child meets criteria. The DSM-5-TR^[3] is a definitive source of the clinical criteria used in practice to formulate a diagnosis of SLD. However, assessment of a child with learning problems can begin in the health care provider’s (HCP’s) office well before formal testing is sought.

A diagnosis of SLD applies to children who struggle significantly to retain and apply academic skills over time, despite provision of intervention, and whose difficulties are not otherwise explained by an intellectual disability. In contrast, children with intellectual disabilities have intelligence levels below the normal distribution (i.e., an intelligence quotient (IQ) less than 70 or more than two standard deviations below the mean), with global deficits in intellectual and adaptive functioning^[1][5]. ‘Labelling’ a child with an SLD should never occur until she or he has received optimal opportunities and support to learn and meet academic expectations for age and stage. For example, the child who misses a substantial amount of school or who is learning English as a second language must be supported in an optimal learning environment before it can be determined that they are not meeting expectations.

The ‘discrepancy model’ used previously for SLD diagnosis is no longer considered a sound basis for assessment. Historically, a learning disability could be diagnosed when there was a significant gap between an individual’s cognitive performance on IQ testing and their academic achievement scores. This model created a “wait to fail” approach that has now been replaced by a “response to intervention” (RTI) or multi-tiered support approach^[8]. In the RTI model, children with learning problems are recognized early and provided with interventions of escalating intensity and individualized support. For children who continue to have learning problems despite such intervention, a psychoeducational assessment becomes important for characterizing their particular learning difficulty and facilitating a diagnosis of SLD. Typically, psychoeducational assessments are conducted on children in grade 2 or higher to allow time for learning interventions to be implemented and subsequent assessment of the student’s progress^[7].

Some children experience learning challenges but do not meet the criteria for SLD, which makes providing proactive, timely support crucial for all children with learning challenges, regardless of formal diagnosis. Providing support as soon as a learning delay is observed rather than waiting for specific test results to confirm a problem aligns better with a needs- and equity-based approach to education and resource provision. Given the scarcity of school psychologists in Canada, especially in remote regions, office-based screening can and should be conducted to establish need for early intervention and rule out other conditions that impact learning^[7].

Psychoeducational assessment

The psychoeducational assessment includes a cognitive component but also assesses academic achievement by reviewing school records, schoolwork, and intake history, and by testing children with validated screening tools. Table 1 shows tests that are commonly used for assessing SLD^[9]-[13]. Additional testing, such as measures of adaptive skills and executive functioning, may be performed to screen for other conditions that impact learning, such as ADHD.

In Canada, timely access to psychoeducational testing via the public health or school system is problematic^[14]. In many regions, children can wait at least 2 years for testing in the public education system. Testing can be arranged and paid for privately, but costs are prohibitive for many families and are often only partially covered by health insurance. Lack of access is particularly concerning for families with limited resources and parents whose workplace does not offer comprehensive health insurance. Exceptionally, First Nations children can receive funding under Jordan’s Principle, while Inuit children are eligible for through the Child First Initiative. Children in the care of child protective services such as Children’s Aid or in foster care are also eligible for special funding for private psychoeducational testing.

Despite barriers to access, HCPs can still support families as they navigate the application and testing process and facilitate access to appropriate supports in the meantime. Equity-deserving populations often require particular attention and care.

Role of the health care provider

While most HCPs have not been trained to conduct psychoeducational testing, they can help identify and provide support to families and children living with learning challenges. Clinic visits should include these lines of inquiry:

1.  A review of recent educational achievement and the child’s learning environment(s):

 a) Try to identify specific learning challenges, such as which aspects of reading, writing, or math are difficult. Samples of schoolwork may help clarify the nature and degree of learning challenges. Ask about steps already taken by family and educators to address learning challenges.

b)   Ask about school absences (frequency, duration, reasons) to identify any barriers to attendance and evaluate the effects of absence. Inquire specifically about children’s access to learning tools, supports, and spaces, including internet access.

c)   If concerns arise, screen for psychosocial factors impeding learning, such as bullying, maltreatment at home, and inadequate sleep or nutrition. 

2.   Medical overview: Conduct a detailed history and physical exam to investigate possible genetic, neurologic, or secondary causes of learning challenges (e.g., acquired brain injury, extreme prematurity, genetic conditions). Vision and hearing tests are recommended to rule out medical factors contributing to learning issues^[15].  Family history may reveal a genetic predisposition for an SLD.

3.   Allied health overview: Review reports from allied professionals (e.g., speech and language pathologist, physiotherapist, occupational therapist) and early childhood educators or teachers, when available. HCPs can provide and review the Canadian Paediatric Society (CPS) Preschool or School-aged questionnaire for teacher to complete^[1]. Review psychoeducational assessment results with families to clarify diagnosis, recommendations, and next steps.

4.  Comorbid health conditions: Consider whether common comorbid conditions are present and contributing to learning challenges, and assess as needed.

5. Advocacy: Support families by helping them advocate for early school-based interventions, which often require a letter, phone call, or a school-based meeting. When learning challenges persist despite such interventions, an SLD may be suspected. Inform families about private testing options, as needed.

6.   Counselling families: Reinforce healthy routines at home: sleep hygiene, screen-time limits, nutrition, and family mealtimes as bases for effective learning. Promote daily shared reading with all families to help expand vocabulary, increase fluency, and build relational health^[16]. Focus on child and family strengths and abilities, to support functioning and promote self-esteem^[17]. The HCP can also recommend relevant community and online resources (e.g., Learning Disability Association Canada, Learning disabilities basics^[18] and About Kids Health; Learning disabilities: Overview^[19])

7.  Consider referring children with complex or multi-faceted conditions to a developmental paediatrician.

Best practice points:

To best evaluate and care for children with a suspected learning disorder (SLD) in community practice, paediatric health care professionals (HCPs) should be ready and informed to do the following:

• Start the process of evaluating and caring for children with a suspected or confirmed specific learning difficulty (SLD). Targeted inquiry, in-office screening, supportive counselling, and intervening early are key steps.
• Review a psychoeducational assessment with families and help interpret results to optimize supports for children with an SLD at home and in school. 
• Advocate with families for timely access to school-based interventions using a stepped approach and increasing intensity of supports as needed. For children with persistent academic struggles, HCPs should help parents advocate for timely access to a psychoeducational assessment.
• Recommend local or community-based resources to support families and children, such as tutoring, library programs, and shared networking and information forums and opportunities.

Acknowledgements

This practice point was reviewed by the Adolescent Health and Mental Health and Developmental Disabilities Committees of the Canadian Paediatric Society, and by the CPS Developmental Paediatrics and Mental Health Section Executives.

CANADIAN PAEDIATRIC SOCIETY COMMUNITY PAEDIATRICS COMMITTEE (June 2023)

Members: Peter Wong  MD (Chair), Jill Borland Starkes MD (Board Representative), Kelcie Lahey MD MSC, Michael Hill MD, Audrey Lafontaine MD, Meta van den Heuvel MD PhD

Liaisons: Richa Agnihotri MD (Community Paediatrics Section)

Principal authors: Justine Cohen-Silver MSc MD FRCPC MPH, Meta van den Heuvel MD PhD, Sloane Freeman MSc MD FRCPC, Jacqueline Ogilvie MSc MD FRCPC, Tara Chobotuk MD FRCPC

Funding
No funding to report.

Potential Conflict of Interest
Dr. Jacqueline Ogilvie is the Interim Medical Director for the Thames Valley Children’s Centre (TVCC). No other disclosures were reported.

References

Disclaimer: The recommendations in this position statement do not indicate an exclusive course of treatment or procedure to be followed. Variations, taking into account individual circumstances, may be appropriate. Internet addresses are current at time of publication.