Transcript Document

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
What is the All Kinds of Minds
Institute?
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Not-for-profit institute
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Mission
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Founded in 1993 by Dr. Mel Levine (Professor of
Pediatrics & Director of the Center for Development
and Learning at the UNC School of Medicine)
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
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Schools Attuned
Student Success Services
Children Who Struggle in School
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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.
Based on longitudinal, population-based
estimates, NICHD estimates that 20% of the
population displays reading disability.
Other Considerations
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Boys outnumber girls by 4:1, at least in part
due to referral bias.
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Causality is generally multi-factorial and
rarely readily apparent.
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Major impact on multiple aspects of child’s
life.
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School problems are by far the most
common developmental problems (perhaps
the most common problem in general)
encountered by pediatricians
AAP Policy Statement: The New
Morbidity Revisited-Pediatrics, 11/01
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“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.
Includes school problems, such as learning
disabilities and attention difficulties.
ADHD and LD
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Significant co-morbidity between ADHD
and reading disabilities (15-45%)
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Co-morbid group demonstrates deficits of both
single groups in additive fashion.
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.
To get started, you need
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Basic knowledge and conceptual framework
Medical and neurodevelopmental issues related
to school performance
 Age and grade specific academic expectations
 Legal and regulatory aspects (IDEA)
 Community resources
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Individuals with Disabilities
Education Act (IDEA)
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1990 revision of Education For All
Handicapped Children Act of 1975.
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Re-authorized in 1997.
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Modified by No Child Left Behind Act.
Fundamental Components of IDEA
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Free Appropriate Public Education (FAPE)
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Individualized Education Program (IEP)
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Procedural Safeguards
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Least Restrictive Environment (LRE)
Fundamental Components of IDEA
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Free Appropriate Public Education (FAPE)
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Individualized Education Program (IEP)
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Procedural Safeguards
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Least Restrictive Environment (LRE)
FAPE
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Special education and related services must
be:
Provided at public expense
 Under professional supervision
 No charge to family
 Meet standards of state education agency
 Include preschool, elementary and secondary
 Conformity with IEP
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Designed to meet students individual needs
Fundamental Components of IDEA
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Free Appropriate Public Education (FAPE)
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Individualized Education Program (IEP)
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Procedural Safeguards
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Least Restrictive Environment (LRE)
Fundamental Components of IDEA
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Free Appropriate Public Education (FAPE)
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Individualized Education Program (IEP)
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Procedural Safeguards
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Least Restrictive Environment (LRE)
Individualized Education Program (IEP)
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Written statement addressing 5 components:
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Developed by multidisciplinary team with precise
knowledge of child’s needs.
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Present level of performance
Annual goals
Specific special education and related services
Projected dates for initiation
Objective criteria and evaluation procedures and
schedules
Potential for pediatrician participation
Parents entitled to participate fully in development
and implementation.
Overview of the Pediatrician’s Roles
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Provide medical home.
Screening, surveillance, and diagnosis.
Referral.
Participation in assessment.
Counsel and advice.
Creation of IEP.
Coordinated medical services.
Advocacy.
AAP Policy Statement-The Pediatrician’s Role in Development and
Implementation of IEP…Pediatrics 1999;104:124-127.
Fundamental Components of IDEA
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Free Appropriate Public Education (FAPE)
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Individualized Education Program (IEP)
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Procedural Safeguards
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Least Restrictive Environment (LRE)
Fundamental Components of IDEA
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Free Appropriate Public Education (FAPE)
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Individualized Education Program (IEP)
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Procedural Safeguards
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Least Restrictive Environment (LRE)
Procedural SafeguardsDue Process Procedures
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Protection for family and children against
unilateral decisions by educational agency.
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Implications for assessment process (i.e.
multidisciplinary and multisourced)
Requirement for parental notification and consent.
Right to impartial hearing.
Right to appeal to courts.
Opportunity to examine all records pertaining to
their children and to add corrections.
Fundamental Components of IDEA
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Free Appropriate Public Education (FAPE)
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Individualized Education Program (IEP)
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Procedural Safeguards
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Least Restrictive Environment (LRE)
Fundamental Components of IDEA
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Free Appropriate Public Education (FAPE)
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Individualized Education Program (IEP)
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Procedural Safeguards
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Least Restrictive Environment (LRE)
Least Restrictive Environment
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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.
All school districts must have continuum of alternative
placements available.
Requirements for LRE may conflict with FAPE.
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Resolution based on best information available to determine
IDEA Definition of Learning Disability
(Legal not Medical!!!!)
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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 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.
Other Common Definition
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Severe discrepancy between ability and
performance
Pediatric Perspective
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School focus is eligibility for services
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Appropriate vs. optimal
Pediatrician’s focus is the child and family
Determine reason for school problems
 Develop intervention strategy that is optimal for the
child
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Medical History
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Identify early risk factors and/or early signs
of learning difficulties
Identify conditions associated with learning
difficulties
Family History
Developmental History
Sleep and Nutrition History
Behavioral and emotional issues
Physical Examination
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Height, weight, head circumference, BP
Assessment of overall physical and pubertal
development
Screen for speech and hearing difficulties
Look for stigmata of systemic disorders
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Chromosomal, phakomotoses, endocrinopathies
Explore any somatic complaints
Neurological Assessment
Key Elements of PENeurological
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Soft signs
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Common
Association with learning differences
Non-specific and rarely contribute to treatment
Signs of significant pathology
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Rare
Important not to miss
Search for Soft Signs
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Synkinetic (mirror) movements
Other associated movements (“overflow”)
Dysdiodochokinesis
Stimulus extinction
Motor impersistence
Choreiform movements
Lateral preference
Left-right discrimination
Roper Starch Worldwide Poll
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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
Provides important insights into attitudes
and concerns about learning problems
Results of Roper Starch Poll
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40% had concerns that their children might have
serious problems with learning or schoolwork.
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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 selfesteem.
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63% of parents feel that children with LD view
themselves as different and not as good as other
children.
SOME OBJECTIONS
TO BEING A LABELED PERSON
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Labels oversimplify and diminish People
Labels may imply “If you’ve seen one, you’ve seen
them all”
Labels can be pessimistic
Labels have inadequate implications for how to
help someone
Labels imply we need to look no further to
understand someone
Labels can become self-fulfilling prophesies
SOME MORE OBJECTIONS
TO BEING A LABELED PERSON
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Labels can imply you can only have 1 problem
Labels may suggest you’ll always be how you are
now
Labels often have criteria that are vague &
arbitrary
Labels can take over a person’s whole sense of
who she is
Labels get used to justify questionable treatments
Labels suggest that variation is invariably a form
of deviation
Rational Approach to Medical
Assessment-Accardo, 1999.
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Detailed history.
Comprehensive PE.
Functional neurodevelopmental assessment.
Performance of appropriate tests.
-Pediatric Clinics of North America 1999;46:845-856.
AKOM Approach
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Non-labeling, phenomenologic.
Identification of specific breakdown points
that account for learning difficulties.
Interdisciplinary assessment resulting in
neurodevelopmental profile.
Pediatrician, psychologist, learning specialist
 Strengths and Weaknesses
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Specific learning plans.
Conceptual Model of Learning and
Productivity in School
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Hierarchical
Four levels
Neurodevelopmental functions
 Subskills, Knowledge and Strategies
 Skills, Sophisticated Knowledge, and Approach
to Learning
 School-Related Outcomes
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An example of a skill and its
component subskills
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Writing, a skill, is composed of several subskills:
Letter formation
 Spelling
 Mechanics (e.g. punctuation, capitalization)
 Written language
 Use of prior knowledge
 Brainstorming (generating ideas)
 Organization
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Important Terms
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Variation
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Dysfunction
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Disability
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Handicap
Variation
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Definition
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Example
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An unusual pattern of style, strength, and/or weakness
in one or more components of developmental function
A strong vocabulary, very good verbal reasoning, but
some weakness in processing lengthy complex
sentences
Effects
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Usually of little or no impact unless complicated by
other factors or unusual expectations
Dysfunction
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Definition
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Example
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An pattern of developmental variation that significantly
impairs performance in a particular developmental
function
A poor vocabulary, trouble finding words, and weakness
of verbal memory-together thwarting overall linguistic
skills
Effects
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Variable, depending on severity, expectations,
employment of compensatory strengths, and presence
of other dysfunctions
Disability
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Definition
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Example
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One or more dysfunctions that result in poor
performance on a particular type of task
A language dysfunction associated with a reading
disability
Effects
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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)
Handicap
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Definition
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Example
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A disability that is uncompensated for and that
compromises a critical area of performance
A reading disability
Effects
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Of high impact
Implications
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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
Adults are able to practice specialties and avoid
areas of weakness while children are required to
be generalists
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Disabilities that may not handicap adults are more likely
to handicap children
Implications for self esteem and mental health
Implications for ultimate success and happiness
AKOM Approach
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Non-labeling, phenomenologic.
Identification of specific breakdown points
that account for learning difficulties.
Interdisciplinary assessment resulting in
neurodevelopmental profile.
Pediatrician, psychologist, learning specialist
 Strengths and Weaknesses
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Specific learning plans.
Neurodevelopmental FunctionsEight Constructs
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Attention
Language
Memory
Spatial Ordering
Temporal-Sequential Ordering
Neuromotor Function
Social Cognition
Higher Order Cognition
Elements of AKOM Learning Plan
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“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.
Specific activities (interventions at the breakdown
points) intended to try to strengthen the weak area
of function.
Activities to strengthen strengths.
Why Demystification?
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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 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.
Why Demystification?
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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 well-demystified student knows he has a
problem, but it’s not so bad – thus sidestepping
both denial and over-reacting.
Components of Demystification
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DESTIGMATIZATION of the demystification
 letting a child know she’s not being singled out; anyone can benefit
from demystification
DELINEATION OF STRENGTHS
 providing highly specific evidence of assets and comparing to other
students
ENUMERATION OF WEAKNESSES or areas needing work on
 using a small number of weaknesses stated before and after the
listing
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)
ALLIANCE FORMATION
 letting a student know that you intend to be available and helpful in
the future (as a mentor and advocate)
Summary
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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.
Conclusion
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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.