Assessment of learning difficulty and cognitive delay

Intellectual disability may be either generalised (cognitive impairment) or specific to one area (learning difficulty). Children with cognitive impairment have below-average IQ, at <70.[1]Harris JC. Developmental neuropsychiatry, volumes 1 and 2. Oxford, UK: Oxford University Press; 1998. The degree of cognitive impairment depends on the underlying disorder and its severity. An IQ of 50 to 70 is classed as mild cognitive impairment. Children with a specific learning difficulty, on the other hand, have difficulties with particular mental tasks but a normal IQ. Examples include difficulties with speech (specific language impairment), reading and writing (dyslexia), and use of numbers (dyscalculia). Although the terms 'learning difficulty' and 'cognitive impairment' have specific definitions, they are sometimes used interchangeably by clinicians.[1]Harris JC. Developmental neuropsychiatry, volumes 1 and 2. Oxford, UK: Oxford University Press; 1998.

Epidemiology

Cognitive impairment affects 2-3% of children.[2]American Academy of Pediatrics. Caring for your school-age child ages 5 to 12. Itasca, IL: AAP Books; 2005. https://ebooks.aappublications.org/content/caring-for-your-school-age-child-ages-5-to-12 Down's syndrome and fetal alcohol syndrome are among the most common identified causes of cognitive impairment.[3]Rasmussen C, Bisanz J. Executive functioning in children with fetal alcohol spectrum disorders: profiles and age-related differences. Child Neuropsychology. 2009;15:201-15. http://www.ncbi.nlm.nih.gov/pubmed/18825524?tool=bestpractice.com The prevalence of learning difficulties is more difficult to determine because of the spectrum of disabilities and the variation in diagnostic criteria.[4]Rey-Casserly C, McGuinn L, Lavin A, et al. School-aged children who are not progressing academically: considerations for pediatricians. Pediatrics. 2019 Oct;144(4):e20192520. https://publications.aap.org/pediatrics/article/144/4/e20192520/38485/School-aged-Children-Who-Are-Not-Progressing http://www.ncbi.nlm.nih.gov/pubmed/31548334?tool=bestpractice.com Most estimates suggest that the lifetime prevalence of learning disability is about 10%; males are more likely to be affected than females. Dyslexia is the most common specific learning disability (affecting about 5% to 12% of children).[1]Harris JC. Developmental neuropsychiatry, volumes 1 and 2. Oxford, UK: Oxford University Press; 1998.[5]Peterson RL, Pennington BF. Developmental dyslexia. Lancet. 2012;379:1997-2007. http://www.ncbi.nlm.nih.gov/pmc/articles/PMC3465717 http://www.ncbi.nlm.nih.gov/pubmed/22513218?tool=bestpractice.com

The majority of conditions associated with both specific learning difficulties and generalised cognitive impairment are developmental in origin, are linked to abnormalities in brain structure and function, and are present from birth. Learning difficulty or cognitive impairment may be part of a syndrome, and there may be a family history of similar difficulties. Generalised cognitive impairment is often associated with a history of delayed developmental milestones; the age at which it becomes manifest varies according to its severity. In some children, mild generalised cognitive impairment becomes more obvious when the child starts attending school.

The English Learning Disabilities Mortality Review (LeDeR) program in 2018 found that the median age at death for 3860 people with learning disabilities (ages 4 years and over) was 60 years for males and 59 years for females.[6]Healthcare Quality Improvement Partnership. The Learning Disabilities Mortality Review – annual report 2018. 21 May 2019 [internet publication]. https://www.hqip.org.uk/resource/the-learning-disabilities-mortality-review-annual-report-2018/#.YSOe5Y5Kg2w

Multidisciplinary team approach

Children who develop new specific learning difficulties or who have recently been identified as having cognitive impairment should be referred to a paediatrician. An acquired disability due to intracranial pathology must be considered if there is an acute onset or a regression of previously acquired skills. However, often the specific learning difficulties or cognitive impairment may have been present for some time but only recently noted (e.g., on starting school).

A multidisciplinary team (MDT) assessment is desirable for accurate diagnosis and advice regarding appropriate interventions and educational placement. An MDT assessment includes the paediatrician or child psychiatrist and allied professionals such as a psychologist and a speech therapist. Children with motor co-ordination difficulties (developmental co-ordination disorder, or dyspraxia) resulting in physical problems with writing may benefit from assessment by an occupational therapist. The role of the clinical psychologist is to identify the child's cognitive ability (IQ, or age-equivalent developmental level, which can be compared with their chronological age). Speech therapists help assess the child's expressive and receptive (understanding) language abilities and compare these with the overall level of cognitive ability. Some children have a discrepancy between cognitive and language abilities. For example, children with autism sometimes have relatively superior non-verbal skills compared with verbal performance. There is evidence that early reading interventions may be particularly helpful in improving expressive and receptive language as well as reading in children with intellectual disability.[7]Reichow B, Lemons CJ, Maggin DM, et al. Beginning reading interventions for children and adolescents with intellectual disability. Cochrane Database Syst Rev. 2019 Dec 5;12(12):CD011359. https://www.ncbi.nlm.nih.gov/pmc/articles/PMC6894923 http://www.ncbi.nlm.nih.gov/pubmed/31805208?tool=bestpractice.com

Cerebral palsy

'Cerebral palsy' is a diagnosis given to children with a static brain injury of varying aetiology (e.g., premature birth, hypoxic-ischaemic injury, meningitis, or intracerebral haemorrhage), associated with a disorder of movement and posture. Cerebral palsy is not a cause of cognitive impairment. However, the two conditions can co-exist, and for this reason a cause-and-effect relationship is often mistakenly assumed both by clinicians and by the general public.[8]Odding E, Roebroeck ME, Stam HJ. The epidemiology of cerebral palsy: incidence, impairments and risk factors. Disabil Rehabil. 2006 Feb 28;28(4):183-91. http://www.ncbi.nlm.nih.gov/pubmed/16467053?tool=bestpractice.com