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Pediatricians and the Management of Learning Disabilities/Differences Paul B. Yellin, MD, FAAP Interim Head, Student Success Clinical Services All Kinds.

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Presentation on theme: "Pediatricians and the Management of Learning Disabilities/Differences Paul B. Yellin, MD, FAAP Interim Head, Student Success Clinical Services All Kinds."— Presentation transcript:

1 Pediatricians and the Management of Learning Disabilities/Differences Paul B. Yellin, MD, FAAP Interim Head, Student Success Clinical Services All Kinds of Minds Institute Clinical Associate Professor of Pediatrics NYU School of Medicine

2 What is the All Kinds of Minds Institute? Not-for-profit institute Not-for-profit institute Founded in 1993 by Dr. Mel Levine (Professor of Pediatrics & Director of the Center for Development and Learning at the UNC School of Medicine) Founded in 1993 by Dr. Mel Levine (Professor of Pediatrics & Director of the Center for Development and Learning at the UNC School of Medicine) Mission Mission To help students who struggle with learning measurably improve their success in school and life by providing programs that integrate educational, scientific and clinical expertise. To help students who struggle with learning measurably improve their success in school and life by providing programs that integrate educational, scientific and clinical expertise. Programs Programs Schools Attuned Schools Attuned Student Success Services Student Success Services

3 Children Who Struggle in School Depending upon the methodology and definition, the incidence of learning disabilities is generally reported to be in the range of 5-10%, sometimes as high as 15-18%. Depending upon the methodology and definition, the incidence of learning disabilities is generally reported to be in the range of 5-10%, sometimes as high as 15-18%. Almost 25% of children experience school difficulties. Almost 25% of children experience school difficulties. Based on longitudinal, population-based estimates, NICHD estimates that 20% of the population displays reading disability. Based on longitudinal, population-based estimates, NICHD estimates that 20% of the population displays reading disability.

4 Other Considerations Boys outnumber girls by 4:1, at least in part due to referral bias. Boys outnumber girls by 4:1, at least in part due to referral bias. Causality is generally multi-factorial and rarely readily apparent. Causality is generally multi-factorial and rarely readily apparent. Major impact on multiple aspects of child’s life. Major impact on multiple aspects of child’s life.

5 School problems are by far the most common developmental problems (perhaps the most common problem in general) encountered by pediatricians School problems are by far the most common developmental problems (perhaps the most common problem in general) encountered by pediatricians

6 AAP Policy Statement: The New Morbidity Revisited-Pediatrics, 11/01 “Reaffirms the Academy’s commitment to prevention, early detection, and management of behavioral, developmental, and social problems as a focus in pediatric practice.” “Reaffirms the Academy’s commitment to prevention, early detection, and management of behavioral, developmental, and social problems as a focus in pediatric practice.” Addresses both increased frequency with which these issues are recognized and increased knowledge base facilitating more effective prevention, early detection, and management. Addresses both increased frequency with which these issues are recognized and increased knowledge base facilitating more effective prevention, early detection, and management. Includes school problems, such as learning disabilities and attention difficulties. Includes school problems, such as learning disabilities and attention difficulties.

7 ADHD and LD Significant co-morbidity between ADHD and reading disabilities (15-45%) Significant co-morbidity between ADHD and reading disabilities (15-45%) Co-morbid group demonstrates deficits of both single groups in additive fashion. Co-morbid group demonstrates deficits of both single groups in additive fashion. Emerging evidence of association between math disabilities and attention deficits. Emerging evidence of association between math disabilities and attention deficits. When ADHD is diagnosed, there should be a high index of suspicion for other learning problems. When ADHD is diagnosed, there should be a high index of suspicion for other learning problems.

8 To get started, you need Basic knowledge and conceptual framework Basic knowledge and conceptual framework Medical and neurodevelopmental issues related to school performance Medical and neurodevelopmental issues related to school performance Age and grade specific academic expectations Age and grade specific academic expectations Legal and regulatory aspects (IDEA) Legal and regulatory aspects (IDEA) Community resources Community resources

9 Individuals with Disabilities Education Act (IDEA) 1990 revision of Education For All Handicapped Children Act of revision of Education For All Handicapped Children Act of Re-authorized in Re-authorized in Modified by No Child Left Behind Act. Modified by No Child Left Behind Act.

10 Fundamental Components of IDEA Free Appropriate Public Education (FAPE) Free Appropriate Public Education (FAPE) Individualized Education Program (IEP) Individualized Education Program (IEP) Procedural Safeguards Procedural Safeguards Least Restrictive Environment (LRE) Least Restrictive Environment (LRE)

11 Fundamental Components of IDEA Free Appropriate Public Education (FAPE) Free Appropriate Public Education (FAPE) Individualized Education Program (IEP) Individualized Education Program (IEP) Procedural Safeguards Procedural Safeguards Least Restrictive Environment (LRE) Least Restrictive Environment (LRE)

12 FAPE Special education and related services must be: Special education and related services must be: Provided at public expense Provided at public expense Under professional supervision Under professional supervision No charge to family No charge to family Meet standards of state education agency Meet standards of state education agency Include preschool, elementary and secondary Include preschool, elementary and secondary Conformity with IEP Conformity with IEP Designed to meet students individual needs Designed to meet students individual needs

13 Fundamental Components of IDEA Free Appropriate Public Education (FAPE) Free Appropriate Public Education (FAPE) Individualized Education Program (IEP) Individualized Education Program (IEP) Procedural Safeguards Procedural Safeguards Least Restrictive Environment (LRE) Least Restrictive Environment (LRE)

14 Fundamental Components of IDEA Free Appropriate Public Education (FAPE) Free Appropriate Public Education (FAPE) Individualized Education Program (IEP) Individualized Education Program (IEP) Procedural Safeguards Procedural Safeguards Least Restrictive Environment (LRE) Least Restrictive Environment (LRE)

15 Individualized Education Program (IEP) Written statement addressing 5 components: Written statement addressing 5 components: Present level of performance Present level of performance Annual goals Annual goals Specific special education and related services Specific special education and related services Projected dates for initiation Projected dates for initiation Objective criteria and evaluation procedures and schedules Objective criteria and evaluation procedures and schedules Developed by multidisciplinary team with precise knowledge of child’s needs. Developed by multidisciplinary team with precise knowledge of child’s needs. Potential for pediatrician participation Potential for pediatrician participation Parents entitled to participate fully in development and implementation. Parents entitled to participate fully in development and implementation.

16 Overview of the Pediatrician’s Roles Provide medical home. Provide medical home. Screening, surveillance, and diagnosis. Screening, surveillance, and diagnosis. Referral. Referral. Participation in assessment. Participation in assessment. Counsel and advice. Counsel and advice. Creation of IEP. Creation of IEP. Coordinated medical services. Coordinated medical services. Advocacy. Advocacy. AAP Policy Statement-The Pediatrician’s Role in Development and Implementation of IEP…Pediatrics 1999;104:

17 Fundamental Components of IDEA Free Appropriate Public Education (FAPE) Free Appropriate Public Education (FAPE) Individualized Education Program (IEP) Individualized Education Program (IEP) Procedural Safeguards Procedural Safeguards Least Restrictive Environment (LRE) Least Restrictive Environment (LRE)

18 Fundamental Components of IDEA Free Appropriate Public Education (FAPE) Free Appropriate Public Education (FAPE) Individualized Education Program (IEP) Individualized Education Program (IEP) Procedural Safeguards Procedural Safeguards Least Restrictive Environment (LRE) Least Restrictive Environment (LRE)

19 Procedural Safeguards- Due Process Procedures Protection for family and children against unilateral decisions by educational agency. Protection for family and children against unilateral decisions by educational agency. Implications for assessment process (i.e. multidisciplinary and multisourced) Implications for assessment process (i.e. multidisciplinary and multisourced) Requirement for parental notification and consent. Requirement for parental notification and consent. Right to impartial hearing. Right to impartial hearing. Right to appeal to courts. Right to appeal to courts. Opportunity to examine all records pertaining to their children and to add corrections. Opportunity to examine all records pertaining to their children and to add corrections.

20 Fundamental Components of IDEA Free Appropriate Public Education (FAPE) Free Appropriate Public Education (FAPE) Individualized Education Program (IEP) Individualized Education Program (IEP) Procedural Safeguards Procedural Safeguards Least Restrictive Environment (LRE) Least Restrictive Environment (LRE)

21 Fundamental Components of IDEA Free Appropriate Public Education (FAPE) Free Appropriate Public Education (FAPE) Individualized Education Program (IEP) Individualized Education Program (IEP) Procedural Safeguards Procedural Safeguards Least Restrictive Environment (LRE) Least Restrictive Environment (LRE)

22 Least Restrictive Environment To the maximum extent appropriate, children with disabilities are educated with children that are not disabled. To the maximum extent appropriate, children with disabilities are educated with children that are not disabled. Special classes, separate schooling, or other removal from regular education environments only when nature and severity of disability is such that education in regular classes with supplementary aides and services cannot be achieved satisfactorily. Special classes, separate schooling, or other removal from regular education environments only when nature and severity of disability is such that education in regular classes with supplementary aides and services cannot be achieved satisfactorily. All school districts must have continuum of alternative placements available. All school districts must have continuum of alternative placements available. Requirements for LRE may conflict with FAPE. Requirements for LRE may conflict with FAPE. Resolution based on best information available to determine Resolution based on best information available to determine

23 IDEA Definition of Learning Disability (Legal not Medical!!!!) The term "specific learning disability" means a disorder in one or more of the basic processes involved in understanding or using language, spoken or written, which disorder may manifest itself in imperfect ability to listen, think, speak, read, write, spell, or do mathematical calculations. The term "specific learning disability" means a disorder in one or more of the basic processes involved in understanding or using language, spoken or written, which disorder may manifest itself in imperfect ability to listen, think, speak, read, write, spell, or do mathematical calculations. DISORDERS INCLUDED- Such term includes such conditions as perceptual disabilities, brain injury, minimal brain dysfunction, dyslexia, and developmental aphasia. DISORDERS INCLUDED- Such term includes such conditions as perceptual disabilities, brain injury, minimal brain dysfunction, dyslexia, and developmental aphasia. DISORDERS NOT INCLUDED- Such term does not include a learning problem that is primarily the result of visual, hearing, or motor disabilities, of mental retardation, of emotional disturbance, or of environmental, cultural, or economic disadvantage. DISORDERS NOT INCLUDED- Such term does not include a learning problem that is primarily the result of visual, hearing, or motor disabilities, of mental retardation, of emotional disturbance, or of environmental, cultural, or economic disadvantage.

24 Other Common Definition Severe discrepancy between ability and performance Severe discrepancy between ability and performance

25 Pediatric Perspective School focus is eligibility for services School focus is eligibility for services Appropriate vs. optimal Appropriate vs. optimal Pediatrician’s focus is the child and family Pediatrician’s focus is the child and family Determine reason for school problems Determine reason for school problems Develop intervention strategy that is optimal for the child Develop intervention strategy that is optimal for the child

26 Medical History Identify early risk factors and/or early signs of learning difficulties Identify early risk factors and/or early signs of learning difficulties Identify conditions associated with learning difficulties Identify conditions associated with learning difficulties Family History Family History Developmental History Developmental History Sleep and Nutrition History Sleep and Nutrition History Behavioral and emotional issues Behavioral and emotional issues

27 Physical Examination Height, weight, head circumference, BP Height, weight, head circumference, BP Assessment of overall physical and pubertal development Assessment of overall physical and pubertal development Screen for speech and hearing difficulties Screen for speech and hearing difficulties Look for stigmata of systemic disorders Look for stigmata of systemic disorders Chromosomal, phakomotoses, endocrinopathies Chromosomal, phakomotoses, endocrinopathies Explore any somatic complaints Explore any somatic complaints Neurological Assessment Neurological Assessment

28 Key Elements of PE- Neurological Soft signs Soft signs Common Common Association with learning differences Association with learning differences Non-specific and rarely contribute to treatment Non-specific and rarely contribute to treatment Signs of significant pathology Signs of significant pathology Rare Rare Important not to miss Important not to miss

29 Search for Soft Signs Synkinetic (mirror) movements Synkinetic (mirror) movements Other associated movements (“overflow”) Other associated movements (“overflow”) Dysdiodochokinesis Dysdiodochokinesis Stimulus extinction Stimulus extinction Motor impersistence Motor impersistence Choreiform movements Choreiform movements Lateral preference Lateral preference Left-right discrimination Left-right discrimination

30 Roper Starch Worldwide Poll Commissioned in 2000 by Emily Hall Tremaine Foundation Commissioned in 2000 by Emily Hall Tremaine Foundation Surveyed a nationwide cross-section of 1,000 adults (age > 18 yo) and an additional sample of 700 parents with children 18 yo) and an additional sample of 700 parents with children < 18 yo Provides important insights into attitudes and concerns about learning problems Provides important insights into attitudes and concerns about learning problems

31 Results of Roper Starch Poll 40% had concerns that their children might have serious problems with learning or schoolwork. 40% had concerns that their children might have serious problems with learning or schoolwork. 44% of these waited for signs of the difficulty to persist for > 1 year before acknowledging the problem. 44% of these waited for signs of the difficulty to persist for > 1 year before acknowledging the problem. Parents fear that being labeled as learning disabled will have a negative effect on their child’s self- esteem. Parents fear that being labeled as learning disabled will have a negative effect on their child’s self- esteem. 63% of parents feel that children with LD view themselves as different and not as good as other children. 63% of parents feel that children with LD view themselves as different and not as good as other children.

32 SOME OBJECTIONS TO BEING A LABELED PERSON Labels oversimplify and diminish People Labels oversimplify and diminish People Labels may imply “If you’ve seen one, you’ve seen them all” Labels may imply “If you’ve seen one, you’ve seen them all” Labels can be pessimistic Labels can be pessimistic Labels have inadequate implications for how to help someone Labels have inadequate implications for how to help someone Labels imply we need to look no further to understand someone Labels imply we need to look no further to understand someone Labels can become self-fulfilling prophesies Labels can become self-fulfilling prophesies

33 SOME MORE OBJECTIONS TO BEING A LABELED PERSON Labels can imply you can only have 1 problem Labels can imply you can only have 1 problem Labels may suggest you’ll always be how you are now Labels may suggest you’ll always be how you are now Labels often have criteria that are vague & arbitrary Labels often have criteria that are vague & arbitrary Labels can take over a person’s whole sense of who she is Labels can take over a person’s whole sense of who she is Labels get used to justify questionable treatments Labels get used to justify questionable treatments Labels suggest that variation is invariably a form of deviation Labels suggest that variation is invariably a form of deviation

34 Rational Approach to Medical Assessment-Accardo, Detailed history. Detailed history. Comprehensive PE. Comprehensive PE. Functional neurodevelopmental assessment. Functional neurodevelopmental assessment. Performance of appropriate tests. Performance of appropriate tests. -Pediatric Clinics of North America 1999;46:

35 AKOM Approach Non-labeling, phenomenologic. Non-labeling, phenomenologic. Identification of specific breakdown points that account for learning difficulties. Identification of specific breakdown points that account for learning difficulties. Interdisciplinary assessment resulting in neurodevelopmental profile. Interdisciplinary assessment resulting in neurodevelopmental profile. Pediatrician, psychologist, learning specialist Pediatrician, psychologist, learning specialist Strengths and Weaknesses Strengths and Weaknesses Specific learning plans. Specific learning plans.

36 Conceptual Model of Learning and Productivity in School Hierarchical Hierarchical Four levels Four levels Neurodevelopmental functions Neurodevelopmental functions Subskills, Knowledge and Strategies Subskills, Knowledge and Strategies Skills, Sophisticated Knowledge, and Approach to Learning Skills, Sophisticated Knowledge, and Approach to Learning School-Related Outcomes School-Related Outcomes

37 An example of a skill and its component subskills Writing, a skill, is composed of several sub- skills: Writing, a skill, is composed of several sub- skills: Letter formation Letter formation Spelling Spelling Mechanics (e.g. punctuation, capitalization) Mechanics (e.g. punctuation, capitalization) Written language Written language Use of prior knowledge Use of prior knowledge Brainstorming (generating ideas) Brainstorming (generating ideas) Organization Organization

38 Important Terms Variation Variation Dysfunction Dysfunction Disability Disability Handicap Handicap

39 Variation Definition Definition An unusual pattern of style, strength, and/or weakness in one or more components of developmental function An unusual pattern of style, strength, and/or weakness in one or more components of developmental function Example Example A strong vocabulary, very good verbal reasoning, but some weakness in processing lengthy complex sentences A strong vocabulary, very good verbal reasoning, but some weakness in processing lengthy complex sentences Effects Effects Usually of little or no impact unless complicated by other factors or unusual expectations Usually of little or no impact unless complicated by other factors or unusual expectations

40 Dysfunction Definition Definition An pattern of developmental variation that significantly impairs performance in a particular developmental function An pattern of developmental variation that significantly impairs performance in a particular developmental function Example Example A poor vocabulary, trouble finding words, and weakness of verbal memory-together thwarting overall linguistic skills A poor vocabulary, trouble finding words, and weakness of verbal memory-together thwarting overall linguistic skills Effects Effects Variable, depending on severity, expectations, employment of compensatory strengths, and presence of other dysfunctions Variable, depending on severity, expectations, employment of compensatory strengths, and presence of other dysfunctions

41 Disability Definition Definition One or more dysfunctions that result in poor performance on a particular type of task One or more dysfunctions that result in poor performance on a particular type of task Example Example A language dysfunction associated with a reading disability A language dysfunction associated with a reading disability Effects Effects Variable, depending on the importance of the affected task and the age and social and/or educational setting of the child (e.g. a reading disability has more impact than a dancing disability) Variable, depending on the importance of the affected task and the age and social and/or educational setting of the child (e.g. a reading disability has more impact than a dancing disability)

42 Handicap Definition Definition A disability that is uncompensated for and that compromises a critical area of performance A disability that is uncompensated for and that compromises a critical area of performance Example Example A reading disability A reading disability Effects Effects Of high impact Of high impact

43 Implications Variations need not be a dysfunction, dysfunction need not create a disability and disability need not create a handicap Variations need not be a dysfunction, dysfunction need not create a disability and disability need not create a handicap Implications are age and setting specific Implications are age and setting specific Adults are able to practice specialties and avoid areas of weakness while children are required to be generalists Adults are able to practice specialties and avoid areas of weakness while children are required to be generalists Disabilities that may not handicap adults are more likely to handicap children Disabilities that may not handicap adults are more likely to handicap children Implications for self esteem and mental health Implications for self esteem and mental health Implications for ultimate success and happiness Implications for ultimate success and happiness

44 AKOM Approach Non-labeling, phenomenologic. Non-labeling, phenomenologic. Identification of specific breakdown points that account for learning difficulties. Identification of specific breakdown points that account for learning difficulties. Interdisciplinary assessment resulting in neurodevelopmental profile. Interdisciplinary assessment resulting in neurodevelopmental profile. Pediatrician, psychologist, learning specialist Pediatrician, psychologist, learning specialist Strengths and Weaknesses Strengths and Weaknesses Specific learning plans. Specific learning plans.

45 Neurodevelopmental Functions- Eight Constructs Attention Attention Language Language Memory Memory Spatial Ordering Spatial Ordering Temporal-Sequential Ordering Temporal-Sequential Ordering Neuromotor Function Neuromotor Function Social Cognition Social Cognition Higher Order Cognition Higher Order Cognition

46 Elements of AKOM Learning Plan “Demystification”- a process through which the child is taught all about his or her strengths and weaknesses using understandable words. “Demystification”- a process through which the child is taught all about his or her strengths and weaknesses using understandable words. Bypass strategies, techniques designed to work around a student’s area of weakness. Bypass strategies, techniques designed to work around a student’s area of weakness. Specific activities (interventions at the breakdown points) intended to try to strengthen the weak area of function. Specific activities (interventions at the breakdown points) intended to try to strengthen the weak area of function. Activities to strengthen strengths. Activities to strengthen strengths.

47 Why Demystification? Students struggling in school often harbor fantasies about what’s “wrong” with them; very often their fantasies are much worse than the reality. Students struggling in school often harbor fantasies about what’s “wrong” with them; very often their fantasies are much worse than the reality. A student may believe she is pervasively defective; therefore, we need to put borders around her areas of dysfunction. A student may believe she is pervasively defective; therefore, we need to put borders around her areas of dysfunction. A student can feel more in control and motivated when, instead of a label, he comes to understand the highly specific breakdowns in learning that are thwarting his school success. A student can feel more in control and motivated when, instead of a label, he comes to understand the highly specific breakdowns in learning that are thwarting his school success.

48 Why Demystification? It is hard for a kid to work on an area of weakness if he doesn’t even know what it’s called. It is hard for a kid to work on an area of weakness if he doesn’t even know what it’s called. A child can benefit from perceiving his weaknesses embedded in a context of strengths, as part of a profile of strengths and weaknesses - which everyone has. A child can benefit from perceiving his weaknesses embedded in a context of strengths, as part of a profile of strengths and weaknesses - which everyone has. A well-demystified student knows he has a problem, but it’s not so bad – thus sidestepping both denial and over-reacting. A well-demystified student knows he has a problem, but it’s not so bad – thus sidestepping both denial and over-reacting.

49 Components of Demystification DESTIGMATIZATION of the demystification DESTIGMATIZATION of the demystification letting a child know she’s not being singled out; anyone can benefit from demystification letting a child know she’s not being singled out; anyone can benefit from demystification DELINEATION OF STRENGTHS DELINEATION OF STRENGTHS providing highly specific evidence of assets and comparing to other students providing highly specific evidence of assets and comparing to other students ENUMERATION OF WEAKNESSES or areas needing work on ENUMERATION OF WEAKNESSES or areas needing work on using a small number of weaknesses stated before and after the listing using a small number of weaknesses stated before and after the listing INDUCTION OF OPTIMISM INDUCTION OF OPTIMISM helping a student feel upbeat regarding the future (e.g., communicating it may be easier to be an adult than a kid) helping a student feel upbeat regarding the future (e.g., communicating it may be easier to be an adult than a kid) ALLIANCE FORMATION ALLIANCE FORMATION letting a student know that you intend to be available and helpful in the future (as a mentor and advocate) letting a student know that you intend to be available and helpful in the future (as a mentor and advocate)

50 Summary Learning problems are extremely common and would benefit from the kind of comprehensive, pediatric approach applied to other chronic problems, like asthma and diabetes. Learning problems are extremely common and would benefit from the kind of comprehensive, pediatric approach applied to other chronic problems, like asthma and diabetes. Every pediatrician should screen for school problems as an integral component of routine child care. Every pediatrician should screen for school problems as an integral component of routine child care.

51 Conclusion Children with learning problems deserve a medical home to provide continuing and ongoing supervision for these chronic problems. Children with learning problems deserve a medical home to provide continuing and ongoing supervision for these chronic problems. Pediatricians should become familiar both with the body of knowledge regarding learning and the community resources to support the appropriate care of these common issues. Pediatricians should become familiar both with the body of knowledge regarding learning and the community resources to support the appropriate care of these common issues.


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