Chapter 48 Learning Disabilities
PATHOPHYSIOLOGY
Learning disabilities are a group of neurologic disorders that affect an individual’s ability to store, process, and produce information. Learning disabilities significantly interfere with educational achievement and performance, and they create a gap between one’s capabilities and performance. Impairment may be in the area of reading, writing, spelling, or mathematical functions. The most commonly identified learning disability is reading disability. Intelligence is generally average or above average in these children. However, academic achievement is markedly below what is expected given the person’s intellect, age, and educational opportunities.
Etiologic factors associated with learning disabilities include genetic predisposition, perinatal and birth injuries, and medical conditions occurring in infancy or childhood, such as head injury, malnutrition, or poisoning. Late effects of cranial irradiation, as well as alcohol or tobacco use during pregnancy, have also been known to contribute to learning disabilities. Mental retardation, emotional or behavioral disorders, and autism are not learning disabilities. Environmental, socioeconomic, and cultural disadvantages do not produce learning disabilities. Learning disabilities can be categorized into several types: reading disorder, mathematics disorder, disorder of written expression, and learning disorder not otherwise specified (Box 48-1).
Box 48-1 Learning Disabilities: DSM-IV Criteria
Reading Disorder DSM-IV Criteria
A. Reading achievement, as measured by individually administered standardized tests of reading accuracy or comprehension, is substantially below that expected given the person’s chronologic age, measured intelligence, and age-appropriate education.
B. The disturbance in criterion A significantly interferes with academic achievement or activities of daily living that require reading skills.
C. If a sensory deficit is present, the reading difficulties are in excess of those usually associated with it.
Mathematics Disorder DSM-IV Criteria
A. Mathematical ability, as measured by individually administered standardized tests, is substantially below that expected given the person’s chronologic age, measured intelligence, and age-appropriate education.
B. The disturbance in criterion A significantly interferes with academic achievement or activities of daily living that require mathematical ability.
C. If a sensory deficit is present, the difficulties in mathematical ability are in excess of those usually associated with it.
Disorder of Written Expression DSM-IV Criteria
A. Writing skills, as measured by individually administered standardized tests (or functional assessments of writing skills), are substantially below those expected given the person’s chronologic age, measured intelligence, and age-appropriate education.
B. The disturbance in criterion A significantly interferes with academic achievement or activities of daily living that require the composition of written texts (e.g., writing grammatically correct sentences and organized paragraphs).
C. If a sensory deficit is present, the difficulties in writing skills are in excess of those usually associated with it.
From American Psychiatric Association: Diagnostic and statistical manual of mental disorders, ed 4, text revision (DSM-IV-TR), Washington, DC, 2000, The Association.
Reading disorders, mathematics disorders, and disorders of written expression can be specifically tested for in the school setting using individualized standardized tests. The child with such disorders will score substantially below what is expected based upon chronologic age and measured intelligence.
Many states will quantify this “gap” between where the child is performing and where the child is expected to perform, and will use this quantification as criteria that will make a child eligible for special education services. The learning disorder not otherwise specified has no written criteria, but the student is performing significantly below age and/or intelligence level in reading, mathematics, and written expression.
Learning difficulties become apparent in the early years of elementary school (kindergarten through third grade). It is estimated that between 25% and 50% of children with learning disabilities have other problems that interfere with their school performance. These associated conditions are attention-deficit/hyperactivity disorder (ADHD), memory problems, emotional and behavioral problems, and problems with social skills. Once a child is assessed for learning disabilities and qualifies for special education services based upon the gap between performance and ability, the school staff works with the parent to develop an individualized educational plan (IEP). The IEP, which is signed by school staff and parents, will include present levels of function, goals and objectives, and time allotted for services on a weekly or monthly basis. The IEP is reviewed annually, and every 3 years the testing process is repeated to determine if the child’s eligibility has changed.
Children with learning disabilities may also have speech and language disorders. The speech and language disorders often fall into general categories of receptive language, expressive language, and articulation. These are considered more as developmental disorders and not true learning disabilities. A child who has an IEP for learning disabilities may also receive services for speech and language disorders that are included on the same IEP.
INCIDENCE
1. Approximately 5% of students in public schools in the United States are identified as having a learning disorder, but up to 20% of the school-aged population may actually have a learning disorder.
2. Approximately 17.5% of public school students are estimated to have problems learning to read.
3. Among children 6 to 12 years of age, specific learning disorders are the most prevalent disability.
4. More than 50% of children receiving special education have specific learning disorders.
5. The high school drop-out rate for students with learning disabilities is 1.5 times higher than that for students in general education.
6. Of students with reading problems, 60% to 80% are male.
7. Male/female prevalence ratio for learning disorders is 4:1 to 5:1.
8. Reading disability accounts for approximately 80% of all learning disabilities.
LABORATORY AND DIAGNOSTIC TESTS
The more severe the learning disability, the earlier the disability will be detected.
1. Intelligence testing that is sensitive to child’s ethnic and cultural background, used to determine intelligence based upon standardized tests (e.g., Wechsler Intelligence Scale for Children, ed 3; Woodcock-Johnson Psycho-Educational Battery—Revised: Tests of Cognitive Ability)
2. Tests of language and memory function, used to test language skills based upon standardized tests (e.g., Test of Awareness of Language Segments, Rapid Automatized Naming Test)
3. Measurements of visual-perceptual skills, used to assess for visual motor learning disabilities and self-concept (e.g., Bender Visual Motor Gestalt Test, Goodenough-Harris Drawing Test)
4. Standardized reading tests, used to test current reading level (e.g., Stanford Diagnostic Reading Test, Gray Oral Reading Test—Revised)
5. Standardized math tests, used to assess current level of math skills on a standardized test (e.g., Key Math—Revised)
6. Standardized written expression tests, used to test written skills on a standardized test (e.g., Test of Written Spelling, ed 2)
MEDICAL MANAGEMENT
The medical management of the child with a learning disability involves coordination with a community-based interdisciplinary team. Special education specialists, general education teachers and counselors, transition specialists, school nurses, job developers, and rehabilitation specialists, including the medical team (child psychiatrists and pediatricians), work with the family to address the child’s long-term needs. Medications may be used to treat associated problems such as ADHD and emotional problems that affect the child’s ability to learn.
NURSING INTERVENTIONS
1. Consult with IEP specialists and educators in adapting strategies in health care settings.
2. Adapt instructional approaches, procedural explanations, and preprocedural preparations to be sensitive to child’s learning disability.
3. Coordinate with special education members of child’s team in formulating child’s IEP as it pertains to child’s health care needs.
4. Facilitate coordination and implementation of child’s IEP while hospitalized.
Discharge Planning and Home Care
1. Coordinate services with members of IEP team and integrate with health care instruction and development of instructional materials.
2. Develop individualized health care plan (IHP). IHP may be written separately by school nurse or integrated as part of IEP–individualized family service plan.
3. Integrate IEP objectives and strategies into child’s health care plan in school setting (refer to Appendix G).
4. Refer to community-based services and support services (see Appendix G).
5. Incorporate adaptations of learning style into discharge teaching.
6. Refer to counseling and/or therapy services—individual, family, or group.
American Psychiatric Association. Diagnostic and statistical manual of mental disorders, ed 4. Washington, DC: The Association, 2000. text revision (DSM-IV-TR)
House AE. DSM-IV Diagnosis in the schools. New York: Guilford Press, 2002.
Ldonline. IDEA update. (website) www.ldonline.org/article.php?id=)&loc=109 Accessed January 14, 2006
National Center for Learning Disabilities. LD at a glance fact sheet. www.ncld.org/LDInfoZone/InfoZone_FactSheet_LD_QuickLook.pdf. Accessed January 14, 2006
National Dissemination Center for Children with Disabilities. Fact sheet #7, 2004. (website) www.nichcy.org/pubs/factshe/fs7txt.htm Accessed January 14, 2006
Selekman J. Learning disabilities: A diagnosis ignored by nurses. Pediatr Nurs. 2002;28(6):630.
Silver L. Doctor to Doctor: Information on learning disabilities for pediatricians and other physicians. (website) www.ldaamerica.us/aboutld/professionals/doctor_to_doctor.asp Accessed January 14, 2006
