Learning disabilities (LDs) refer to several disorders that may affect the acquisition, organization, retention, comprehension, or the use of both verbal or nonverbal information. An important aspect of defining this condition is to identify its exclusions, meaning that individuals with LDs have only specific issues with learning, but they preserve an average or above-average intelligence quotient. Further, learning disabilities cannot be attributed to emotional disturbance, cultural difference, or disadvantage. The core tenet of LD juxtaposes the disparity between a child's poor academic achievement and his expected intellectual potential.
Leading theorists suggest the etiology of LDs to be of neurobiological origin, with the contribution of both hereditary and environmental factors. They do not precipitate as the result of a deficit in sensorimotor functioning, such as poor eyesight or hearing as corrective lenses and hearing aids do not resolve LDs. Unfortunately, the precise etiology still eludes experts.
LDs are nearly twice as prevalent in children with chronic illnesses as compared to healthy controls. Learning disabilities are present in approximately 5% of school-aged children globally. In the Us, data collected by the National Survey of Children's Health suggest a lifetime prevalence of 10%. Risk factors include a family history of LD, poverty, premature delivery, prenatal alcohol exposure, TBI, and in the setting of other neurodevelopmental disorders. The most common LD is dyslexia, which accounts for at least 80% of LDs. LDs often exist comorbidly with other disorders such as oppositional defiant disorder, attention deficit hyperactivity disorder, anxiety, and obsessive-compulsive disorder.
Application of innovative insight awarded by recent advances in neuroscience has allowed experts to propose putative pathogeneses for LDs. For example, fMRI studies have revealed hypoactivity in the left hemisphere of dyslexic patients. Additional hypotheses include aberrations within the corticostriatal systems responsible to language and communication.
Although presentations of patients with LDs will be individualized and protean, there are general patterns that can help the health care provider more reliably identify the underlying pathology. Often children will present for evaluation after experiencing continued difficulties in school. Frequently, children with LDs will also demonstrate deficits in overall functioning, not solely isolated to the academic setting. For example, hindrances at school may be related to academic difficulty, negative self-concept, behavior issues, or interpersonal relations. It is essential to inquire about the child’s past school history, diet, family history of similar concerns, and developmental milestones, including social skills.
Commonly recognized specific learning disabilities include:
Individual factors (intrinsic) and environmental factors will influence the clinical presentation. Intrinsic factors include comorbid psychiatric conditions and personality traits. Environmental factors encompass home, school, programs, etc. LDs do not often exist in isolation, rather, they will present comorbidly with other LDs and psychiatric conditions. The most common comorbid disorders are attention deficit hyperactivity disorder, autism, bipolar disorder, anxiety, depression, and oppositional defiant disorder. Some studies suggest the existence of LDs in 20-70% of children with psychiatric conditions. 
The evaluation of LDs begins with the exclusion of both organic and functional differential diagnoses. Once other disorders are ruled out, the health care provider is encouraged to follow diagnostic guidelines set out by the Diagnostic and Statistical Manual of Mental Disorders (DSM). Evaluation should synthesize developmental, medical, familial, and educational histories of the patient.
As per the DSM-5:
In addition, comprehensive neuropsychological testing can further guide the clinician towards the correct diagnosis. Commonly administered tests include: Woodcock-Johnson-III and Wide Range Achievement Test to evaluate academic achievement; the Adaptive Behavior Assessment System-II and the Vineland Adaptive Behavior Scale-II to assess adaptive behavior; the Conners Rating Scale, ADHD Rating Scale-IV (formerly DuPaul scale) and NICHQ Vanderbilt Parent and Teacher Assessment Scales to evaluate for attention and hyperactive disorders; the Wechsler Intelligence Scales for Children—Fourth Edition (WISC-IV) for evaluation of general cognition; the Achenbach Child Behavior Checklist (CBCL) for assessment of general behavior; the Clinical Evaluation of Language Fundamentals (4th Ed.)
The diagnosis and treatment of a child with learning disabilities depend on the coordinated and ongoing collaboration of an interprofessional team that can be composed of educators, educational remediation specialists, psychologists, special services, and physicians. Speech therapists can help evaluate and treat any underlying oral language difficulties that are often associated with dyslexia. Occupational and physical therapists will treat fine motor, gross motor, proprioceptive, balance, and sensory-processing disorders that can coexist in some children with learning disabilities. Clinical psychologists can help children better cope with the social challenges associated with learning disabilities. Educational therapists or educators trained in learning disabilities are also part of the multidisciplinary team treating children with LDs.
As with other neurodevelopmental conditions, it is important to monitor developmental progression, inquiring about the child’s academic performance and school behavior. For those with associated behavioral problems, appropriate treatment should be considered as well. Furthermore, several remedial programs are established, they frequently work with children having reading and writing difficulties.
Specific educational strategies in management:
As mentioned previously, LDs can mimic other neurodevelopmental or sensorimotor disorders. It is paramount to distinguish between the aforementioned learning disabilities and other syndromes, factors, and disorders that can interfere with the process of acquisition and the use of speaking, listening, reading, reasoning, writing, and/or mathematical abilities, such as, intellectual disability, hearing or vision impairment, and ADHD. Environmental conditions to be included on the differential list include chronic truancy, domestic violence, physical or emotional abuse, caregivers' behavioral health problems, or substance use. Furthermore, specific learning disabilities can present similarly and mimic each other.
The prognosis will depend on the severity of the learning disability as well as the subsequent intervention and compliance. Although challenging, with adequate remediations, assistance, and educational accommodations children with learning disabilities can achieve functional status.
There is an increased risk of low academic performance in children with learning disabilities that can affect their social and career trajectory. Negative self-concept, stemming from continued academic failure, can precipitate awkward interpersonal relationships and depression. Behavioral problems can manifest as well, as children with LDs demonstrate resistance to authoritative figures or demands. These complications can result in an aversive disposition towards school, leading to more frequent absenteeism or truancy.
Deterrence begins before the patient is ever suspected of having an LD. It is imperative for children to be adequately stimulated academically to ensure proper development. Early intervention and support have demonstrated robust therapeutic value in the mitigation of the severity of LDs and subsequent sequelae. The emphasis on quality instruction prior to the onset of and LD was the impetus for the No Child Left Behind Act, which ensures quality instruction and intervention services for all students.
Interprofessional care is crucial in the identification and treatment of learning disabilities. Interprofessional care encompasses educators, educational remediation specialists, special services, physicians, speech and occupational therapists, physical therapists, clinical psychologists, and educational therapists. Communication among members of the team improves outcomes. [Level 5]
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