Tackling literacy-related learning difficulties in children By Dr Sandra Marshall & Professor Pamela Snow
Tackling literacy-related learning difficulties in children, by Dr Sandra Marshall & Professor Pamela Snow. First Printed in Australian Doctor, 21st August 2019. Here’s how to identify the children who need help
Early intervention is key.
Literacy-related learning difficulties are common. One in five students in Year 4 across Australia failed to achieve international benchmarks in the 2016 Progress in International Reading Literacy Study assessment.1
This study found that 19% did not achieve the intermediate benchmark and 6% did not reach the minimum (low) benchmark for literacy.
Further, more than half of Australians aged 15-19 have a literacy level that is “insufficient to meet the complex demands of everyday life and work”.2
Reading difficulties in early life are strongly linked with behavioral and emotional difficulties, a pattern that can persist into adulthood and is sometimes characterised as a “school-to-prison pipeline”.3
Low literacy levels are endemic in youth justice and adult criminal justice systems.4
Given the potential life-altering impact of such learning difficulties, it is vital that affected children are identified early and receive appropriate intervention. Unfortunately, Australian education systems have shown a reluctance to systematically adopt scientifically validated approaches to reading instruction and lack systematic screening processes to identify struggling students in a timely manner.5,6
This means that a proportion of struggling students are in fact ‘instructional casualties’, and that many students are identified only once they have begun to fail, if at all. The co-occurrence of reading and behavioural difficulties is particularly worrying in developmental terms. In such instances, early and appropriate referral to developmental specialists, including paediatricians, psychologists, occupational therapists and speech-language pathologists, can have a significant impact.
This article aims to help GPs identify children with learning difficulties relating to literacy, in order to help facilitate early interventions that have the potential to alter the trajectory for children at risk.
LEARNING DIFFICULTIES AND DISABILITIES
The term ‘learning difficulties’ refers to academic struggles in the areas of reading, writing, spelling, and numeracy, which are not associated with a diagnosed disorder and are amenable to appropriate intervention.7 Around 16-20% of children experience such difficulties, which may be influenced by a range of factors, such as disrupted schooling, psychosocial stressors and sub-optimal instruction.7 Learning disabilities, on the other hand, are less prevalent, affecting around 2-4% of the population.7 These are regarded as neurological in origin. Learning disabilities are generally more resistant to intervention.
In practice, these terms are often used interchangeably, and it can be difficult in individual cases to discern where a learning difficulty ends and a learning disability begins. In this article, the term learning difficulty will be used to apply to both groups. In either, the effects may persist beyond childhood and into adulthood.
The DSM-5 includes significant changes to the classification of learning difficulties.
First, the DSM-5 uses the term ‘Specific Learning Disorder’ with specifiers to characterise the particular manifestations of learning difficulties in three major academic domains: reading, writing and mathematics. Previously these were classified as separate disorders. And second, the requirement for a discrepancy between IQ and achievement was eliminated.
This is significant because it recognises that reading skills are not simply a function of IQ but are also a product of the quality of instruction a child receives. Having an intellectual disability doesn’t mean a child cannot learn to read, though it will impact on the conceptual complexity of written text the child can process.
Dyslexia is a specific learning disability that accounts for a small but significant proportion of specific learning disorder. It is characterised by difficulties with accurate and/or fluent word recognition (decoding) and poor spelling skills.
These typically result from a deficit in the phonological (sound system) component of the language system, and are unexpected in relation to the child’s other cognitive abilities and exposure to effective classroom instruction.8
Secondary consequences include problems in reading comprehension and reduced reading experience, which can impede the growth of vocabulary and background knowledge. Vocabulary growth and background knowledge become increasingly important across the school years, as these underpin full academic engagement and success.
Dyslexia can occur across the full range of intellectual abilities. It is best considered as a continuum — there are no clear cut-off points or internationally agreed diagnostic criteria. Co-occurring difficulties may be seen in aspects of language, motor co-ordination, mental calculation, concentration and personal organisation, but these are not, by themselves, markers of dyslexia.
A good indication of the severity and persistence of dyslexic difficulties can be gained by examining how the individual responds to evidence-based intervention.9 Contrary to some popular myths, dyslexia is not a ‘gift’ that bestows special abilities in other areas of a child’s functioning. It is a debilitating and distressing condition that needs to be managed by experts.
DISADVANTAGE AND LOW LITERACY
The long-term effects of low literacy and its comorbidities are well known.
People with low literacy are more likely to experience low self-esteem, poor school engagement, truancy, school drop-out, school exclusion (suspensions and expulsions), internalising mental health problems (anxiety and depression, self-harm, suicidality and substance abuse), and externalising mental health problems (attentional disorders and conduct disorder).
They are also at greater risk of long-term unemployment, unstable housing and incarceration.10
In addition, it is important to acknowledge that not all families have the resources to pay out-of-pocket for specialist assessments to receive a formal diagnosis.
It should also be noted that irrespective of whether a formal diagnosis of dyslexia is made, children with reading difficulties require expert support and intervention from appropriately qualified practitioners.
A diagnosis of dyslexia should not ‘privilege’ support for one child with a formal diagnosis over another who is recognised to have reading difficulties, even if not formally diagnosed as dyslexia.
All children who struggle with reading, writing, and spelling should receive appropriate and timely interventions to maximise their chances of academic success and minimise the risk of mental health sequelae.
IDENTIFYING AFFECTED CHILDREN
Children with learning difficulties usually present with secondary consequences of their school underachievement, such as anxiety, depression, psychosomatic symptoms, behaviour disturbance and school refusal.10
Questions that can help a GP assess such children can include:
How is school going?
How often do you miss a day of school?
How is your reading and spelling going?
It is worth asking parents whether there is a family history of people who struggle with reading, as genetic factors account for 45-75% of variance in reading skills.11
This will not change management but can be reassuring to children and their parents in understanding their difficulties.
If the response to such questions is suggestive of learning difficulty, it is worth then exploring whether this has ever been formally assessed, whether school is providing any assistance and if so, what.
In children with suspected learning difficulties, it is important to ensure hearing and vision are within normal limits, and take appropriate steps if not.
Primary dyslexia and learning disabilities are complex neurocognitive conditions, and are not caused by sensory impairments alone.12
As with all paediatric conditions, treatment involves the whole family.
It is important to assure all involved that the child is not at fault and that they are not trying to be troublesome.
It is useful to make early contact with classroom teachers and the school leadership team, such as the principal and/or the literacy leader.
GPs can encourage parents to do so or contact directly if needed.
In some school jurisdictions, students have access to on-site allied health services and it is important to ensure the school is mobilising these appropriately.
Consider writing to their school requesting further diagnostic information about the child’s progress.
It is also important to ensure there is an appropriately qualified multidisciplinary team around the child.
This should include an educational psychologist, speech-language pathologist, occupational therapist, and a developmental paediatrician where possible.
Unfortunately, sizeable out-of-pocket costs can limit access to such services.
If appropriate, a GP Management Plan and Team Care Arrangement can be undertaken to enable Medicare-subsidised allied health care.
Where there is co-existing mental illness, a Mental Health Care plan can aid access to psychological care.
Support parents to avoid pseudoscience.
There is an enormous ‘snake-oil’ industry attached to learning difficulties and unscrupulous, non-evidence-based therapies abound.
These often make elaborate claims about improving everything from attentional skills to emotional self-regulation and motor control (and everything in between), frequently charge a great deal of money, and always entail an opportunity cost.
Professor Snow recently published an Australian text for parents, Making Sense of Interventions for Children with Developmental Disorders, which provides accessible information about common disorders, as well as a critique of more than 170 widely promoted interventions and strength (or otherwise) of their evidence base.12
GPs can encourage parents to seek information and support from reputable sources (see Resources).
Learning difficulties are common and have many underlying causes.
With early identification and provision of appropriate supports, children with reading difficulties can make substantial and significant gains.
These gains promote the likelihood of school retention and academic success, and reduce the risk of secondary emotional and behavioural sequelae.
GPs play an important role in asking about school progress and advocating for appropriate services and referrals to assist students who are struggling to make up lost ground.
Box 1. DSM-5 Specific Learning Disorder diagnosis criteria
All four of the following criteria must be met for a DSM-5 Specific Learning Disorder diagnosis:
1. Difficulties in at least one of the following areas for at least six months despite targeted help:
(a) Reading (eg, inaccurate, slow and only with much effort);
(b) Understanding the meaning of what is read;
(d) Written expression (eg, problems with grammar, punctuation or organisation);
(e) Understanding number concepts, number facts or calculation; and
(f) Mathematical reasoning (eg, applying math concepts or solving math problems)
2. Academic skills are substantially below what is expected for the child’s age, and cause problems in school, work or everyday activities.
3. Difficulties start during school-age (although some people don’t experience significant problems until adulthood when academic, work and day-to-day demands are greater).
4. Learning difficulties are not due to other conditions, such as intellectual disability, vision or hearing problems, a neurological condition, adverse conditions such as economic or environmental disadvantage, lack of instruction, or difficulties speaking/understanding the language.
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Dr Sandra Marshall is a GP in Gawler, SA. She is Chairperson of Code REaD Dyslexia Network Australia Ltd, a national not-for-profit organisation that advocates for people with dyslexia.
Professor Pamela Snow is a psychologist and speech pathologist. She has expertise in transition to literacy in the early years, oral language skills of youth offenders, and needs of young people in state care.
10. Snow, P.C. (2016). Elizabeth Usher Memorial Lecture: Language is literacy is language. Positioning Speech Language Pathology in education policy, practice, paradigms, and polemics. International Journal of Speech Language Pathology, 18(3), 216-228