Evaluation of learning difficulty and cognitive delay

Sudden change in cognitive or learning ability

Children whose cognitive ability or learning ability changes acutely, or who develop specific acute difficulties in the classroom (e.g., declining visual ability or deterioration in handwriting ability), should be referred to a pediatric neurologist. The urgency of referral depends on the rate of change. If there is a sudden change in ability in a previously well child, referral is more urgent and intracerebral pathology needs to be excluded.

A history of severe headaches that are worse in the morning, vomiting, visual disturbance, a newly developed squint, or focal neurologic deficit is suggestive of a space-occupying lesion. Subacute development of attentional problems and new learning difficulties and behavioral problems may suggest a childhood-onset neurodegenerative disease, such as cerebral adrenoleukodystrophy (in boys).

A detailed neurologic exam is essential. Abnormal neurologic findings indicate the need for urgent cranial imaging with either CT or MRI scanning. Episodic lapses in attention or speech in a previously normal child, or especially in a child with a prior history of seizures, may suggest new absence or focal seizures, which should be investigated with an electroencephalogram (EEG) in both wakefulness and sleep.

If the neurologic exam is normal, cranial imaging may not be essential and further investigations will depend on the clinical history, parental wishes, and progress of symptoms. Educational and psychological assessment may be beneficial.

Education

There has been a move towards including children with disabilities in mainstream education, with additional support from teachers or learning support assistants. Although this may be appropriate for some children, those with cognitive disabilities or complex neurodevelopmental disorders (e.g., children with cerebral palsy affecting all 4 limbs, or core autism) may be better provided for in specialist schooling.