Learning – AFP 1999

Patients:

1 As part of the ongoing care of children, ask parents about their children’s functioning in school to identify learning difficulties.

  • Parental concerns, usually when the child fails to achieve academic milestones alongside his/her peers (report cards, etc)
  • Can be first identified by teachers who initiate referrals to special education teams or for formal psychometric testing and diagnosis
  • Early identification = better outcomes, therefore ask routinely about child’s performance in school
  • Consider a learning disorder with any of the following concerns: academic, behavioral, attention, or social interaction problems

Have a low threshold for considering a learning disorder in children at risk, which includes:

  • Family history of learning disorders
  • Poverty, Understimulating environment
  • Premature
  • Developmental or mental health disorders (ADHD, autism, anxiety, depression, etc)
  • Neurologic disorders (seizures, neurofibromatosis, Tourette syndrome)
  • Chromosomal disorders (Fragile X, Turner, etc)
  • Chronic medical conditions (diabetes, etc)
  • Traumatic brain injury, CNS infection or radiation

Pervasive Developmental Disorders

Autism, childhood disintegrative disorder, Rett disorder, Asperger syndrome, PDD not otherwise specified

Autism
  • 2/3 of pt lacks communication skills
  • Before 3yo withg ≥ 6 features (≥ 2 from social category)
  • Deficits in 3 main areas
  1. Social interaction
    1. impaired nonverbal behaviour: eye contact, getures, expression
    2. Failure to make appropriate peer relationship
    3. lack of sharing interests, achievements
    4. lack of emotional reciprocity
  2. Communication 
    1. Delayed/ absent verbal speech or ability to converse
    2. Repetitive use of language
    3. Absence of age-appropriate imaginary play
  3. Restricted and repetitive behaviours, interests, and activities
    1. Inflexible stereotypical hand or body movements, eg rocking
    2. Routines, mannerisms, preoccupations
Asperger Syndrome
  1. Better knowledge of language, higher cognitive functioning, and more interest in social activities
  2. Atypical social interaction skills with extreme behavioural rigidity and rituals
    1. Impaired nonverbal behaviours: expression, eye contact, postures, gestures
    2. Impaired ability to make peer relationship
    3. Lack of emotional reciprocity
    4. May not respect social boundaries, one-sided conversations about a topic obsessively, lack of interest in other activities, disregards how interested the listener is, avoidant or intense gaze, abnormal facial expressions
  3. No cognitive or milestone delays except social interaction
  4. Restricted repetitive behaviours, interests, and activities

2 In children with school problems, take a thorough history to assist in making a specific diagnosis of the problem (e.g., mental health problem, learning disability, hearing).

  • Early detection improves outcome – try to ask about learning difficulties at routine visits

Five areas of potential difficulty: (always consider & ask about)

  1. Intelligence – reasoning, computing
  2. Academic achievement – ask about education and learning with general Q about functioning at school ( listening, speaking, writing)
  3. Attention/concentration / task completion
  4. Perceptual – vision, hearing, and motor
  5. Behaviour – language & social skills

Hx, O/E, Ix to r/o medical / psychosocial / psychiatric causes

  • OPQRST
  • Medical – AOM, Fe deficiency, hearing difficulties
  • Trauma, physical or verbal abuse
  • Birth: perinatal events, pregnancy hx, family hx
  • School performance / attendance, behavioural problems, hobbies, substance use
  • Developmental delays – milestones especially language

Formal diagnosis requires psychometric testing (administered by psychologist or educator)

Note: lab work is not usually necessary, and physical examination is often normal


3 When caring for a child with a learning disability, regularly assess the impact of the learning disability on the child and the family.

Educate parents about their child’s condition


4 When caring for a child with a learning disability, ensure the patient and family have access to available community resources to assist them.

Multidisciplinary team members:

  • Parents,, teachers, educators, counselors, admin,
  • GP, Peds, psychologist, OT/PT, speech and language specialist, social workers, RN

5 To maximize the patient’s understanding and management of their condition,

a) Determine their willingness to receive information,

b) Match the complexity and amount of information provided with the patient’s ability to understand.

Use SPIKES for sharing bad news

  • SETTING up the interview,
  • Assessing the patient’s PERCEPTION
  • Obtaining the patient’s INVITATION,
  • Giving KNOWLEDGE
  • Addressing the patient’s EMOTIONS with EMPATHIC responses

Self Learning:

6 Continuously assess your learning needs.

7 Effectively address your learning needs.

8 Incorporate your new knowledge into your practice. 


References:
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Posted in 57 Learning, 99 Priority Topics, FM 99 priority topics, OB

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