A CHILD WITH LEARNING DIFFICULTIES
History
Simon is 7 years old. He has been brought to the community paediatric clinic at the local children’s centre by his mother and grandmother. He was referred for a medical assessment to help prepare a statement of special educational needs. His notes indicate that he has been seen previously at the children’s centre by speech and language therapists due to speech delay, and by the occupational therapist because he was very clumsy. The correspondence indicates that a lot of appointments were missed and eventually he was lost to followup. He is the second child of non-consanguineous parents. He attends the same mainstream school as his 9-year-old brother, who has no problems at school. His father works as a delivery driver but his mother does not work. Simon was born at term and has longstanding problems with eczema and constipation. He was admitted to hospital once after scalding himself with boiling water from a kettle. He is reported to be fully immunized, although his Red Book has been lost. His mother has difficulty recalling his developmental milestones, but thinks that he walked at about 20 months and spoke his first word at about 30 months. He managed to potty-train at about 4.5 years, although he still soils himself occasionally. He used to be a contented child who would sit quietly for long periods, but his behaviour became increasingly aggressive when he started school. His mother thinks his eyesight is fine and his hearing is fine when he wants to listen. His mother and grandmother think that, overall, he is a slow learner, but they aren’t particularly worried about him.
Examination
Simon appears quite slight for his age, his height is 115 cm (ninth centile) and his weight is 18 kg (second centile). He has quite a long, thin face and large ears but otherwise looks similar to his mother. He sits quietly beside his mother through most of the consultation. He speaks very little voluntarily and generally answers questions with a ‘yes’ or a ‘no’. Cardiovascular, respiratory and abdominal examinations are normal. Neurological examination reveals normal tone, power and reflexes in the upper and lower limbs. He has rather flat feet, and his knees hyperextend when standing still. His gait is normal, but he cannot stand on one leg for more than a few seconds and he seems quite clumsy when running. His eye movements and facial movements appear normal. He will not tolerate fundoscopy and is generally uncooperative with further cranial nerve assessment.
Questions
• What is a statement of educational needs?
• What further assessment is important?
• What causes should be considered for Simon’s problems?
Medicine
If a child’s school cannot provide all of their needs, the local authority may carry out an assessment to find out what the child’s special educational needs (SEN) are and how they can be supported. The findings are documented in a statement of SEN (usually just called a ‘statement’). This describes the child’s SEN and the assistance he or she requires. The process requires assessments by the child’s school, an educational psychologist, a doctor and other relevant professionals. The medical assessment should identify any features that may indicate specific underlying diagnoses, look for any treatable contributing factors and describe the child’s current level of function and medical needs. It is essential to check hearing and vision. The history suggests Simon may have developmental delay in multiple areas and he probably has global learning disability. He may have ligamentous laxity, with associated dyspraxia. He has chronic eczema and constipation, which may affect his ability to participate fully at school. His behavioural problems may be secondary to his learning difficulties and frustration at school, or may be an independent problem. Fragile X syndrome and Duchenne muscular dystrophy need to be considered as underlying diagnoses, but much more assessment is also needed.
Examples of causes of learning difficulties
Congenital causes
• Chromosome disorder
• Fragile X syndrome
• Duchenne muscular dystrophy
• Congenital infection
• Fetal alcohol syndrome Acquired causes
• Traumatic brain injury
• Meningitis
• Psychosocial deprivation
Examples of contributing factors in learning difficulties
Problem
Solution Hearing impairment
Hearing aids, specialist teaching
Visual impairment Glasses, modification of classroom
Chronic medical condition Optimize medical care
Epilepsy Make diagnosis, anti-epileptic drugs
Autistic spectrum disorders Specific teaching strategies
Dyspraxia Occupational therapy
Neglect Intervention by social services
KEY POINTS
• Children with learning difficulties may need a statement of special educational needs.
• There may be remediable problems contributing to a child’s overall difficulties, e.g. deafness.
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