Principal Author: Joseph H. Beitchman, M.D. This Summary was developed by the Work Group on Quality Issues: William Bernet, M.D., Chair, and John E. Dunne, M.D., former Chair; Maureen Adair, M.D., Valerie Arnold, M.D., R. Scott Benson, M.D., Oscar Bukstein, M.D., Joan Kinlan, M.D., Jon McClellan, M.D., and David Rue, M.D. AACAP Staff: L. Elizabeth Sloan, L.P.C. The full text of the Practice Parameters for the Assessment and Treatment of Children and Adolescents with Language and Learning Disorders is available to Academy members on the World Wide Web (www.aacap.org) and appears in the October 1998 supplement to the Journal. The full text of these parameters was reviewed at the 1997 Annual Meeting of the American Academy of Child and Adolescent Psychiatry. Both the full text and this Summary were approved by AACAP Council on April 20, 1998. Reprint requests to AACAP, Communications Department, 3615 Wisconsin Avenue N.W., Washington, DC 20016. ©1998 by the American Academy of Child and Adolescent Psychiatry.

ABSTRACT

This summary provides an overview of the recommendations contained in the Practice Parameters for the Assessment and Treatment of Children and Adolescents with Language and Learning Disorders. These disorders are among the most common developmental disorders. The diagnosis of language and learning disorders (LLDs) requries a discrepancy, based on age and intelligence, between potential and achievement. The clinician collaborates with parents and school personnel to clarify the diagnosis, implement appropriate treatment and remediation, and monitor progress. The clinician also is instrumental in identifying and treating comorbid conditions. Long-term prognosis depends on the type and severity of the language or learning disorder, the availability of remediation, and the presence of a supportive family and school environment. Key Words: Language, learning, disorders, disabilities, diagnosis, treatment, children, adolescents, practice parameters, guidelines.

These parameters give the clinician direction in assessing and treating children and adolescents with LLDs. Recommendations are based on extensive review of the literature and clinical consensus among experts in the subject. These parameters are not intended to define the standard of care; nor should they be deemed inclusive of all proper methods of care or exclusive of other methods of care directed at obtaining the desired results. The ultimate judgment regarding the care of a particular patient must be made by the clinician in light of all the circumstances presented by the patient and his or her family, the diagnostic and treatment options available, and available resources. The literature review, including references, and the rationale for specific recommendations are contained in the complete document (American Academy of Child and Adolescent Psychiatry, in press). Language and learning disorders are the largest group of disorders requiring special services in the schools, accounting together for more than three-quarters of all children or adolescents in special education. Many children are first referred for psychiatric evaluation or treatment because behavioral difficulties of preschool, or later conflicts around school attendance, school work, or homework. In many cases, incipient or previously undetected LLDs are at issue. Behavioral difficulties may be an attempt by the child to cope with the frustrations of attempting tasks that are difficult to comprehend or for which he or she has deficient skills. For children whose LLDs have already been diagnosed, referral may be made for associated emotional or behavioral problems. Parents, along with teachers and other professionals, may need help to recognize the importance of LLDs in the child's emerging emotional or behavioral problems. Approximately 50% of children with LLDs have a clinically significant comorbid Axis I psychiatric diagnosis. Furthermore, the presence of LLDs contributes to persistence of symptoms of comorbid disorders and complicates their treatment. High rates of comorbidity between LLDs and attention-deficit/hyperactivity disorder, conduct disorder, anxiety disorders, and to a lesser extent, mood disorders have been reported. Psychiatrists often see children with LLDs who may not have comorbid Axis I disorders, but perfomance anxiety, poor peer relationships, decreased self esteem, and family conflicts are nonetheless common in these children. In these instances psychiatric intervention can mitigate or prevent impairment that could lead to the development of clinical psychiatric disorders . There have been changes in the way LLDs are conceptualized in DSM-IV. Social skills deficits are not included as criteria for learning disorders, and voice disorders and selective mutism are considered diagnoses within the language disorders category. The definition of learning disabilities has been the subject of controversy for many years and the clinician needs to be aware that definitions other than those of the DSM-IV are in use. The key issue concerns the definition of learning disabilities as based on age—discrepant achievement versus IQ—discrepant achievement. Public schools have their own diagnostic criteria and often differ in their interpretation of what constitutes a significant discrepancy between a child's academic achievement and potential as measured by intelligence tests. Schools also may differ in whether documentation of cognitive processing disorders, such as perceptual-motor problems, is required to establish diagnostic eligibility. Clinicians should be aware that accumulated research has failed to support the validity of distinctions between age—discrepancy and IQ—discrepancy definitions of learning disabilities. Theoretically guided research has helped advance understanding of the nature of speech, language and learning disorders, identifying heritability as a factor in some of these disorders. Moreover, research has led to improved methods of remediation for LLDs. More than ever, clinicians should be aware of appropriate interventions for LLDs, not only to make effective referrals, but also to monitor treatment progress in coordination with psychiatric or psychopharmacologic interventions. Available treatments also have been the subject of controversy. Interventions such as whole-language approaches and perceptual motor training, once in favor, are no longer considered preferred treatments. The clinician can be pivotal in helping the child and family address the social, emotional, behavioral, and family problems that are common among children with LLDs. Clinicians should be familiar with the Individuals with Disabilities Education Act (IDEA) (Public Law 94-142), which defines the level of disability necessary for a child or adolescent to be eligible for special education services in public schools and mandates the development and implementation of an Individual Education Plan (IEP). In addition, in cases in which the child might not qualify for formal special education service under IDEA, Section 504 of the Rehabilitation Act requires schools to provide classroom accommodation or intervention for the child's learning or behavior problems

ASSESSMENT

The diagnosis of language or learning disorders depends on the developmental and family history, the clinical presentation and evaluation, and review of test results and other available reports. A key clinical finding is the presence of immature forms of speech or language beyond the age at which it would normally be present, or difficulty following or understanding age-appropriate connected speech, such as conversations or stories. Review of the child's preschool or school records can be informative regarding academic achievement, the onset and the description of symptoms in these settings, the appropriateness of previous assessments, response to prior interventions, and history of disciplinary referrals. On the basis of the history, presentation, clinical evaluation, and available test results, the clinician should determine whether a language or learning disorder is present and whether further psychoeducational or speech and language testing is required. As an aid in deciding whether further language, cognitive, or academic testing is required, or to better understand the child's or adolescent's communication skills, office-based clinical assessments of cognitive skills can be helpful. When the clinician suspects or determines that the child has an LLD, referral for psychoeducational and speech and language testing is essential, particularly if prior school assessments are incomplete or inconclusive. At a minimum, current or recent testing (within the past year) should include individual tests of IQ, academic achievement, and speech and language functioning. Lists of intelligence, academic achievement, and speech and language tests commonly used in the diagnosis of language and learning disorders are included in the full parameters. In interviewing the child with a language disorder for comorbid Axis I disorders, the clinician must be aware that the child may have difficulty with oral expression and with language comprehension, and should adjust the interview process accordingly. In addition to a determination of the presence of a language or learning disorder, the clinician should identify other issues that may require therapeutic intervention, such as comorbid Axis I diagnoses, the child's attitude toward peers, concerns with self-esteem, conflicts with parents regarding homework, and parental beliefs or accusations that the child is lazy, unmotivated, or slow. The clinician should explore such possible causes of, or contributors to, poor academic achievement or speech and language disorders as significant physical or sensory deficits, an impoverished or disorganized home, abuse or neglect, excessive school absences, frequent school changes, or lack of opportunity for instruction. The cultural and linguistic appropriateness of tests used to establish functional deficits must also be reviewed. Though subject to controversy, diagnosis of language or learning disorders rests on the discrepancy between the child's potential ability and his or her current performance. However, the clinician needs to be aware of other definitions of learning disabilities, especially those that are not based on an IQ—achievement disrcrepancy. Careful consideration should be given to differential diagnoses such as mental retardation, motor skills disorder, medical or neurologic disorders, and other Axis I disorders. The relevance of concurrent emotional or behavioral disorders to the child's deficits in speech, language, or learning must be assessed. It is possible that psychiatric disorders may artificially lower IQ performance or academic achievement. In these instances, amelioration of the psychiatric disorder would be a prerequiste to academic progress.

TREATMENT

Psychotherapy for social, behavioral, and psychiatric symptoms should be tailored to take into account the child's specific language and cognitive deficits. Parent support, consultation, and management training may be needed to help the family develop a supportive home environment and a consistent home—school reinforcement program. The clinician should determine the need for and provide psychotherapy, cognitive-behavioral therapy, other psychosocial interventions, and medication therapy as indicated. Referral to appropriate support groups for children with speech, language, and learning disorders may also be helpful. Individual treatment of the child should include goals of minimizing disability and maximizing potential through problem-solving, social support, study habits, encouragement in extracurricular athletic or other activities, and help with educational and career decisions. For the speech, language, and learning disorders themselves, the clinician should have an educational and monitoring role. The clinician, in collaboration with school personnel and other professionals, should educate parents, other relevant caregivers, and the children themselves about the nature of speech, language, or learning disorders and help establish realistic academic goals. Clinicians can assist the family in finding and assessing the relevance of various interventions, including those therapies without demonstrated efficacy for speech, language, or learning disorders . The clinician also should ensure that parents understand their rights under the Individuals with Disabilities Education Act (IDEA) and help prepare them for an Individualized Education Plan (IEP) meeting. The parents, or the clinician on the parents' behalf, should inform the school in writing of the child's need for special education services. Once so informed, IDEA requires the school to construct a plan to take into account the child's learning and behavioral needs. If the child is ineligible for special education services under IDEA, Section 504 of the Rehabilitation Act may be applicable. A list of variations in school or classroom placement as specified in IEPs is included in the full parameters. There are a variety of special education programs for children with language disorders, learning disabilities, emotional or behavioral disorders, and other problems for which the child should receive appropriate services. Children may remain in regular classrooms with special assistance, or may need specialized settings for all or part of their school day. With parental consent, the clinician can attend the IEP meeting to facilitate collaboration between school personnel and the parents, and when appropriate, the child. The clinician also can provide information on comorbid disorders and psychosocial factors. In collaboration with school personnel, the clinician should help monitor the appropriateness of school or class placement and educational and school interventions. If parents prefer, referrals to private schools or clinics for learning or language disorders may be made. As the child grows older, accommodations for instruction in academic subjects such as social studies or science may be required. Individual or small-group tutoring in specific subjects may be necessary.

REFERENCE

American Academy of Child and Adolescent Psychiatry (1998). Practice Parameters for the Assessment and Treatment of Children and Adolescents with Language and Learning Disorders. J Am Acad Child Adolesc Psychiatry 37(10suppl)