Pediatric Annals

EDITORIAL: A Pediatrician's View 

An Update on Learning Disabilities

Milton I Levine, MD

Abstract

Most parents today look to their pediatrician for advice on all questions concerning their children including behavior, emotions, and education. The practicing pediatrician should have an understanding of these problems and should be capable of dealing with them according to the most recent knowledge.

As a pediatrician involved in the area of child development, I have been deeply interested in the learning disabilities of children since my earliest years of practice in the 1930s. At that time we were primarily concerned with those children of average or higher intelligence who could not learn to read. The problem was not new, having been discussed since the end of the last century by physicians, ophthalmologists, educators, and some psychologists. Later on, the learning difficulties were expanded to include children with short attention spans, some with hyperactivity, those who were constantly distracted, and some who could not leam mathematics.

What caused these difficulties? Was there a cerebral dysfunction either congenital or due to some perinatal damage? How much was due to emotional or environmental problems? Could they be related to any substance in the diet? How much, if any, was due to glandular malfunction? Most of us, in dealing with learning problems, have used such terms as dyslexia, minimal brain dysfunction, and perceptual difficulties.

In the late 1930s, Bradley described the effective use of an amphetamine (Benzedrine) in countering hyperactivity, limiting distraction, and increasing the attention span. In more recent years, most pediatricians have obtained good results using methylphenidate (Ritalin®) and pemoline (Cylert®). Although these drugs aid considerably in countering learning disabilities due to hyperactivity, distractibility or short attention span, they do not improve such conditions as primary dyslexia or acalculia (educational difficulty in mathematics).

But, as I noted before, our basic concern relates to the cause of a child's educational disability. All pediatricians realize that emotional and environmental difficulties can easily and frequently upset a child to such a degree that he or she is unable to achieve competently at school, often daydreaming, and having a short attention span. In unearthing these problems and directing the parents, the pediatrician can often be of the greatest help.

In most cases the emotional or environmental base is not clearly defined and other causes must be sought. In the past there have been numerous attempts to seek a cause and to treat the suggested cause. One was the use of megavitamins. As a matter of fact, there was a school in New York City run by a psychiatrist who attempted to control educational difficulties by the use of tremendous doses of vitamins. I learned that one of my patients was a pupil at the school and was receiving large doses of multivitamins at least four, if not five, times a day. I spoke to the psychiatrist, argued with him, and finally reported him to the Department of Education and the Department of Health of New York State. The boy did not improve after having been under such treatment for over three months, and I induced the parents to withdraw him from the school. I might add that in 1976 the American Academy of Pediatrics, on the basis of studies, reported no proof of any effectiveness of the use of megavitamin therapy for learning disabilities.

Another approach was fostered by Doman and Delacato of Philadelphia. They felt that the body normally goes through certain definite sequential stages in proper development. For instance, if a child did not go through a creeping stage, there would be various difficulties later on. Among the conditions they attempted to cure were learning difficulties, as well as cerebral palsy and mental…

Most parents today look to their pediatrician for advice on all questions concerning their children including behavior, emotions, and education. The practicing pediatrician should have an understanding of these problems and should be capable of dealing with them according to the most recent knowledge.

As a pediatrician involved in the area of child development, I have been deeply interested in the learning disabilities of children since my earliest years of practice in the 1930s. At that time we were primarily concerned with those children of average or higher intelligence who could not learn to read. The problem was not new, having been discussed since the end of the last century by physicians, ophthalmologists, educators, and some psychologists. Later on, the learning difficulties were expanded to include children with short attention spans, some with hyperactivity, those who were constantly distracted, and some who could not leam mathematics.

What caused these difficulties? Was there a cerebral dysfunction either congenital or due to some perinatal damage? How much was due to emotional or environmental problems? Could they be related to any substance in the diet? How much, if any, was due to glandular malfunction? Most of us, in dealing with learning problems, have used such terms as dyslexia, minimal brain dysfunction, and perceptual difficulties.

In the late 1930s, Bradley described the effective use of an amphetamine (Benzedrine) in countering hyperactivity, limiting distraction, and increasing the attention span. In more recent years, most pediatricians have obtained good results using methylphenidate (Ritalin®) and pemoline (Cylert®). Although these drugs aid considerably in countering learning disabilities due to hyperactivity, distractibility or short attention span, they do not improve such conditions as primary dyslexia or acalculia (educational difficulty in mathematics).

But, as I noted before, our basic concern relates to the cause of a child's educational disability. All pediatricians realize that emotional and environmental difficulties can easily and frequently upset a child to such a degree that he or she is unable to achieve competently at school, often daydreaming, and having a short attention span. In unearthing these problems and directing the parents, the pediatrician can often be of the greatest help.

In most cases the emotional or environmental base is not clearly defined and other causes must be sought. In the past there have been numerous attempts to seek a cause and to treat the suggested cause. One was the use of megavitamins. As a matter of fact, there was a school in New York City run by a psychiatrist who attempted to control educational difficulties by the use of tremendous doses of vitamins. I learned that one of my patients was a pupil at the school and was receiving large doses of multivitamins at least four, if not five, times a day. I spoke to the psychiatrist, argued with him, and finally reported him to the Department of Education and the Department of Health of New York State. The boy did not improve after having been under such treatment for over three months, and I induced the parents to withdraw him from the school. I might add that in 1976 the American Academy of Pediatrics, on the basis of studies, reported no proof of any effectiveness of the use of megavitamin therapy for learning disabilities.

Another approach was fostered by Doman and Delacato of Philadelphia. They felt that the body normally goes through certain definite sequential stages in proper development. For instance, if a child did not go through a creeping stage, there would be various difficulties later on. Among the conditions they attempted to cure were learning difficulties, as well as cerebral palsy and mental retardation. They would exercise children by reenacting creeping and other early childhood physical activities. The American Academy of Pediatrics, in conjunction with other national organizations, issued a statement in 1982 in which it concluded, after conducting studies, that this method of treatment was without merit.

Then, in the mid-70s, Dr. B. F. Feingold proposed another approach to the problem of hyperactivity, one of the primary problems associated with learning difficulties. He claimed that food additives, such as artificial coloring and synthetic flavors, were responsible for hyperactivity in many children. He reported cases but had no controls. In my practice, 1 saw only two boys who rigidly followed the Feingold diet. I noticed no change in their hyperactivity. Several studies have been made which reported that the Feingold diet was ineffective in treating hyperactivity in all but a very few (1% to 2%) of the children under observation.

A little over 10 years ago the idea was promulgated that refined sugar intake caused hyperactivity, conduct difficulties, and learning problems. This idea, widely publicized, was also found to be unjustified according to several scientific studies. The care of children with learning disabilities has been found to be most successful when given the attention of teachers trained in special education.

The discussion of this whole problem is under the Guest-Editorship of Dr. Drake D. Duane, Associate Professor of Neurology at the Mayo Medical School in Rochester, Minnesota. Dr. Duane, a national authority on the subject of dyslexia, notes in the first article that there is a new classification of learning disabilities, including attention deficit disorders, developmental reading disorder, developmental arithmetic disorder, language disorders, and articulation disorders. One important area in this paper deals with the question of whether learning disabilities may be considered biologic in origin. Dr. Duane presents and discusses not only aberrant electroencephalograms, but also the abnormal brain findings in five consecutive cases of deceased dyslectics. If the biologic etiology is correct, an interesting intrauterine approach is suggested, at the time when the embryonic brain is developing.

Dr. Duane has selected as his contributors authorities in attention deficit disorders, nonverbal learning disabilities, language disorders and mathematical disabilities.

The second contribution is on "Attention Deficit: The Diverse Effects of Weak Control Systems in Childhood." It has been written by Dr. Melvin D. Levine, Professor of Pediatrics at the University of North Carolina School of Medicine, and Director of the Clinical Center for the Study of Development and Learning, University of North Carolina, Chapel Hill. I might add that Dr. Levine has for years been recognized as a leader and authority on the subject of learning disorders.

This present paper discusses one area of learning disorders - attention deficits. In this well-organized and informative article, Dr. Levine discusses children with sensory distract ibility (visual, auditory, or tactile), those who daydream, and among other problems the lack of motor control and behavior control. The most common complication of attention deficit, Dr. Levine notes, is chronic success deprivation which generates low self-esteem, anxiety, and reactive depression. After carefully discussing these effects, methods of evaluation are detailed. A valuable section of this article deals with the management of these children with attention deficit. This is an excellent article and contains a great deal of information of value to all pediatricians who wish to understand the learning problems of their patients and the best approach to management.

The next contribution deals with "Nonverbal Learning Disabilities" and is authored by Doris J, Johnson of Northwestern University, Evanston, Illinois. The symptoms of this condition vary individually, but are manifested by such abnormalities as disturbances of spatial orientation, and difficulty in problem solving that requires observation, analysis, and synthesis. Apparently some of these problems are due to acquired right hemisphere dysfunction or damage.

It is interesting that generally children with nonverbal learning disabilities have high verbal but low performance scores on the Wechsler Intelligence Scale for Children. Most of these children have difficulty with handwriting, mathematics, physical education and art. Symptoms during the various age periods are discussed.

The following article covers "Language Disorders of Childhood and Adolescence," and is written by Anthony S. Bashir, PhD, of the Children's Hospital, Boston College; Elisabeth H. Wiig, PhD, Boston University; andJulesC. Abrams, PhD, Hahnemann Medical University, Philadelphia.

This condition is often evident in preschool days when parents notice that a child does not seem to always understand what is said, does not comply with requests or follow directions. Sometimes it is difficult to comprehend the meaning of what the child is saying. Later such children may have problems understanding spoken or written language, problems of oral and written language production, and articulation disorders. But, as the authors note, other problems arise as these children grow older. Among these is the inability to understand specific core vocabularies within the curriculum, such as science and social studies. Such children also have difficulty in oral explanations and descriptions, and because of limited sound production may rely on gestures for communication. These children are at a high risk for academic failure and also at a high risk for psychiatric disorders. Unfortunately, the condition is chronic.

The final paper discusses "Mathematical Disabilities," a problem that has received considerable attention. It has been contributed by Katherine Garnett, EdD, Associate Professor, Department of Special Education, Hunter College, City University of New York, New York City; and Jeannette E. Fleischner, EdD, Chairman of the Department of Special Education, Teachers College, City University of New York, New York City. This intrinsic mathematical learning disability known as acalculia has been estimated to occur in approximately 6% of school aged children.

The present article is a comprehensive study of this problem which has been recognized as an entity only in the past 10 or 15 years. The authors review the literature, suggesting that lesions in various regions of the cortex are responsible for the marked arithmetic difficulty.

I remember some years ago, when faced with normally bright children who could not fathom mathematics, we looked for some emotional shock at the period when they were first learning numbering, summation, and calculation. Traumas we looked for were the loss of a parent, serious illness, the birth of a sibling, or anything causing severe anxiety. This we took to be a block in the normal development, a theory that has not been proven by studies.

The authors of this article have presented a careful and interesting study of all known factors relating to acalculia, including the principles of remedial instruction. This is an area where the pediatrician, teacher, and expert in special education must work hand in hand to aid the child in reaching his or her full potential.

10.3928/0090-4481-19870201-04

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