School age children with learning
difficulties
Causes of learning difficulties
• An intellectual disability
• Specific learning difficulties
• Physical health problems. Sometimes these cause a child to
miss school and get behind. Sometimes illness or medicines
make it hard to learn.
• Vision or hearing problems
• Attention problems - Attention Deficit Hyperactivity Disorder
(ADD or ADHD)
• Family problems or problems at school (such as being
bullied) that worry a child - so she is not able to think about
her school work
• Behaviour problems
Typical Presentations to GP
• My child is not learning…
• School teacher suggested I go to my doctor to get
him referred
• He’s only reading at yellow and he should be at
gold!!
• I think he has dyslexia/auditory processing disorder
etc etc.
What to do?
• Refer or reassure
• Know key information for referral
• Know where to refer (brainstorm…regional
variation…)
Curriculum levels by year group
Curriculum levels by year group
Reading Levels
Note!
• Not all learning problems belong in health.
• For children who’s difficulties are solely educational,
the family should be directed back to the school.
• Even when there are health or disability needs that
need to be addressed, education will still have the
major role.
Special Education in NZ
• The Ministry of Educations vision is a fully inclusive
education system
– “Every day, every child learns and succeeds”
– target of 100% of schools demonstrating
inclusive practices by 2014
– “When schools are demonstrating inclusive
practice, they adapt to fit the student rather than
making the student adapt to fit the school.”
Moderate learning needs
The SEG Grant
• The Special Education Grant (SEG)
• All schools receive a Special Education Grant to
support children with special education needs. The
amount each school receives is based on how many
children it has and its decile ranking.
• Schools have flexibility over how they spend their
Special Education Grant, based on the needs of the
children in their school.
• Most schools have Special Education Needs
Coordinators (SENCO)
RTLB service
• Resource Teachers: Learning and Behaviour
(RTLBs)
– RTLBs are trained teachers who work with
children experiencing learning or behaviour
difficulties. They might provide a classroom
teacher with special teaching strategies, they
might introduce class or school-wide programmes
or they might work directly with a child or with
small groups of children.
High or very high needs
• Ongoing Resourcing Scheme (ORS) provides support for
children with severe needs or multiple needs. This scheme
provides support for additional teachers, teachers’ aides,
specialists and items a child might need in the classroom.
• Communication Service provides support for children who
have difficulties with talking, listening and understanding
language.
• Severe Behaviour Service provides support for children
experiencing severe behaviour difficulties. More details about
this service.
• The School High Health Needs Fund provides a teacher’s
aide for a child with a medical condition that requires special
care in order for them to be able to attend school safely.
The Ongoing Resourcing Scheme
• The Ongoing Resourcing Scheme (ORS) provides
resources for a very small group of students (7000)
throughout New Zealand who have the highest need
for special education. These students have this level
of need throughout their school years.
• Students are eligible when they meet one of nine
criteria. They require intervention from specialists
and/or specialist teachers for access to the New
Zealand Curriculum and/or adaptation of curriculum
content.
ORS cont…
• To meet the criteria they must have significant
educational needs that arise from extreme or severe
difficulty with any of the following:
– Learning, hearing, vision, mobility, language use
and social communication
• or moderate to high difficulty with learning,
combined with any two of:
– hearing vision mobility language use and social
communication.
Hemi meets criterion 5
• Hemi (5 yrs 4 mths) has been supported through an early intervention
programme since he was six months old. He follows the routines at
kindergarten with constant verbal and physical prompting. He is able to
finger feed, drink from a cup and help with getting dressed. Hemi has
been on a toileting programme and is starting to indicate when he wants
to go by holding himself.
With frequent adult prompting, Hemi can build a tower of three blocks,
match two colours and do a three-piece form board puzzle using trial and
error. Hemi makes circular scribbles on paper using a fist grip to hold the
pencil. He can put a spade `in' a bucket on request when playing in the
sandpit.
• Hemi will briefly look at a book with his mother and sometimes label a
familiar picture. Hemi communicates using single words but often uses
sounds and gestures. He likes to be with other children but does not
understand turn taking or sharing and will take what he wants from others.
Criterion 5…cont
• At five, they are learning skills and developing
knowledge usually achieved by children up to or
sometimes just beyond 2½ years of age.
• Nine- and ten-year-old students will still be learning
skills and concepts usually demonstrated
independently by four-year-old children.
• Towards the end of their schooling students who
meet Criterion 5 will still be working within Level One
of the New Zealand Curriculum through activities
appropriate to their age level. When they leave
school they will require supported employment and
other relevant services.
Moving on…
• Intellectual Disability
• Specific Learning Difficulty.
Intellectual Disability
What is intellectual disability?
• “Intellectual disability is characterised by deficits in
general mental abilities, such as reasoning,
problem solving, planning, abstract thinking,
judgement, academic learning and learning from
experience. The deficits result in impairment of
adaptive functioning…fails to meet standards of
personal independence and social responsibility
in…daily life” *
• Onset of intellectual and adaptive deficits during the
developmental period.
*from DSM5
Signs of Intellectual Disability in
Young Children
• Language delay: expressive and receptive
• Delays in self-cares : self-feeding, toileting, dressing
• Cognitive delay: Difficulties with memory, problem-
solving, and logical reasoning
• Social delays
• Gross motor delays infrequent
• Behaviour difficulties common
• ID more likely among children with seizure
disorders, microcephaly, macrocephaly, history of
intrauterine or postnatal growth retardation,
prematurity,
Deficits in general mental abilities
• Significantly sub-average intellectual functioning.
• IQ of approximately 70 or below on an individually
administered IQ test.
• The level of disability may be further classified as
Profound, Severe, Moderate or Mild.
Impairment of adaptive
functioning
deficits or impairments in present adaptive functioning
in at least two of the following areas:
communication
self care
home living
social and interpersonal skills
use of community resources
self direction
functional academic skills
work, leisure, health, and safety.
Formal measures of Adaptive
Functioning…
Why assess for ID?
• There are two main reasons to assess for Intellectual
Disability
– 1) to help understand the child and to help family,
friends and teaching staff have realistic expectations
of them
– 2) to establish eligibility to health funded disability
services.
• Access to education funded services is not determined
on the basis of a diagnosis of intellectual disability but on
the education service’s own functional in depth
assessment of current skills and rate of learning.
Role of the NASC
• Any person can request a Needs Assessment from
a NASC
• requests for ID Eligibility Assessments are
generated by the NASC themselves.
• The NASC makes a request for ID eligibility
assessment if they believe the person is in need of
services and requires eligibility for those services to
be established.
• Variable access to psychologists around NZ
• Wait times for ID eligibility assessments can be long.
Summary
• Assessment of ID requires assessment of
intellectual ability using a formal measure.
• Severity of impairment based on adaptive
functioning rather than IQ test scores alone.
Specific Learning Disorder
A small matter of terminology…
• In the UK intellectual disability is called Specific
Learning Disability…not to be confused with Specific
Learning Difficulty
• And then there’s the “dys”es…
• Dyslexia
• Dysgraphia
• Dyscalculia
• Dyspraxia (or developmental coordination disorder)
Definitions
• SPELD
– “Dyslexia, ADHD, Dyspraxia and Dyscalculia are
all Specific Learning Disabilities”
• Ministry of Education
– “Dyslexia is a term used to describe a range of
persistent difficulties with reading and writing, and
often including spelling, numeracy or musical
notation.”
Definitions …cont
• In DSM-IV - reading disorder, maths disorder,
disorder of written expression.
• In DSM5 specific learning disorder is now a single,
overall diagnosis.
• The DSM5 criteria describe shortcomings in
general academic skills and provide detailed
specifiers for the areas of reading, mathematics,
and written expression.
Specific Learning Disorder
Diagnosis requires:
• Persistent difficulty learning “keystone” academic skills (3Rs)
• Symptoms may include inaccurate or slow and effortful
reading, poor written expression that lacks clarity, difficulties
remembering number facts, or inaccurate mathematical
reasoning.
– Unlike motor and language skills, academic skills have to
be taught and learned explicitly
– SLD disrupts normal pattern of learning academic skills
– Not a consequence of lack of opportunity to learn or poor
teaching.
– Persists despite targeted assistance.
Specific Learning Disorder
• Current academic skills must be well below the average range of scores in culturally and linguistically appropriate tests of reading, writing, or mathematics. May also see average achievement sustained by extraordinarily high levels of support. Avoidance of activities that require academic skills.
• Readily apparent in early years but may not be manifest fully till learning demands have increased and exceed individuals limited capacity.
• Learning difficulties are considered specific for four reasons.
– Not attributable to ID, GDD
• “Unexpected academic underachievement”
– Not attributable to hearing and vision disorders, neurological or motor disorders.
– Not attributable to social disadvantage, absenteeism
– May be restricted to one academic skill or domain
A local definition of dyslexia
• Persistent literacy learning difficulties
• In otherwise typically developing children
• Despite exposure to high quality evidence based
literacy instruction and intervention
• Due to an impairment in the phonological processing
skills required to learn to read and write
• Prof William Tunmer Massey University
Definitions…cont
• Keeping it simple
– “the term ‘specific learning difficulties’ is… used
…to describe the educational problems of
children who underachieve relative to their
general cognitive ability.”
• In NZ Dyslexia (meaning specific learning
difficulties) was formally recognised by the Ministry
of Education in October 2007
Assessments and Treatments
• Teacher
• RTLB service
• Special exam conditions
• Private services: SPELD, Kip McGrath…
• Central Auditory Processing
Out there but evidence??
• Behavioural Optometry
• Irlen Lenses
• DORE Programme
Keeping it simple…what to ask?
• What are the concerns?
• Are they “just” about school? (If he could keep up at
school would you have any other worries)
• Were there developmental concerns in the
preschool years?
Keeping it simple…where to refer
• Learning in school only – redirect for conversations
in education
• Learning plus difficulties with adaptive skills across
settings – referral to developmental services
• Mental health comorbidities – consider CAMHS
services
Over to Catherine
DyspraxiaDevelopmental
coordination Disorder
Developmental coordination disorderDSM 5
• The acquisition and execution of coordinated motor skills is substantially below that expected given child's age and opportunity for skill learning and use.
• Difficulties are manifested as clumsiness as well as slowness and in accuracy of motor skills
• Motor skills deficit significantly and persistently interferes with ADLs
• Onset in developmental period
• Not better explained by ID or visual impairment or neurological condition
Dyspraxia: DCD or DCD plus?
• Affecting fine and/or gross motor coordination, in children and adults.
• Additional problems planning, organising and carrying out movements in the right order in everyday situations.
• Dyspraxia can also affect articulation and speech, perception and thought
• Frequently coexists with • Attention Deficit Hyperactive Disorder (ADHD),
• Dyslexia,
• Language disorders and
• Social, emotional and behavioural impairments.
How common?
- Depends on definition
- Avon Longitudinal study – 1.8% at 7.5 years
- Denmark birth cohort – 3.6%
- DSM-IV - estimated 7%
- Around 5% by definition from Movement ABC
Assessment
Personally• Similar approach to ASD• Thorough history• Complete exam• Could it be anything else?
Venn diagram again!
Comparison With Intellectual disability
ID
• Low cognitive and functional-adaptive scores
Dyspraxia
• IQ> 70 (may have wide scatter of ability)
• Functional adaptive skills below IQ
Comparison With ASD
ASD
• Sensory processing differences
• Clumsy
• Poor organisation
• Poor emotional regulation
• Difficulty with friendships
• Restricted interests
• Repetitive behaviours
DCD
• Sensory processing differences
• Clumsy
• Sensory processing differences
• Clumsy
• Poor organisation
• (May have mirror movements)
Comparison With Inattentive ADHD
Inattentive ADHD
• Easily distracted
• Poor organisation
• Poor emotional regulation
• Difficulty with friendships
• Meet full DSM criteria ADHD
DCD
• Easily distracted
• Poor organisation
• Poor emotional regulation
• Difficulty with friendships
• Gestalt – main issue coordination and processing
• More motor difficulties
How can we help
Not eligible for NASC referral
May be eligible for :• Child Disability Allowance – depends
• Child Development Service – e.g OT – Yes (mostly)
School supports as discussed
Higher bar to access MOE OT
Assistive technology - access increasing
Special Exam conditions
What causes it?
• Traditionally an exclusion diagnosis
• i.e. no neurological disorder identified
• Is associated with
• Prematurity
• Gross motor delay
• Occurs more frequently in
• ASD
• ADHD
Outcome
• Dsy-schoolia
• As an adult easier to work to your strengths• BUT
• Persistent increase psychiatric comorbidity
• Poor driving
• ?Ongoing issues with inattention, organisation
Practical considerations
• Have spare uniform, stationary
• Emailed homework
• Change into school uniform after breakfast
• Baking!• From very early on• Teaches following a stepwise process
• Homework• Dictation• Is it a writing or a learning task?
• Secondary school transition
Over to Juan…