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…