Evaluating and Treating School-Aged Children with Neurodevelopmental Disorders: A Developmental Pediatrics Perspective on How to Make a Complicated Process More Efficient

Tim Jordan, MD, Developmental Pediatrician, Providence Sacred Heart Children’s Hospital

Children between the ages of 6 and 12 who have neurodevelopmental disorders constitute a significant portion of most pediatric and primary care providers’ patient populations. Most of these diagnoses fall under four distinct categories collectively known as the “Four A’s”: autism, attention-deficit/hyperactivity disorder (ADHD), anxiety, and academic problems. These disorders tend to become more noticeable and impactful in older children due to the rapid expansion of social, academic, attention, and behavioral demands in this developmental stage.

In early November, during Ground Pediatric Rounds, we provided recommendations to make the diagnostic and treatment process for these types of disorders easier for primary care providers. This would enable them to handle these issues more independently and only refer to specialist providers when necessary. We discussed each disorder individually, providing diagnostic and treatment recommendations that would make referrals to developmental specialists more efficient.

Diagnosis: Identifying the “4 A’s”

Diagnosing the four disorders can be intricate and time-consuming, even when the diagnosis appears straightforward. A child initially referred for autism or ADHD may, in fact, have a substantially different diagnosis such as anxiety or academic difficulties. This occurs because all four diagnoses share certain symptoms. For example, children with both autism and ADHD display poor attention skills, reduced executive functions, and social challenges, albeit for different reasons. Generally, children with autism simply do not consider it essential to do many things, including paying attention to things that are not of interest to them, and often lack interest in interacting with other children. Children with ADHD, on the other hand, have a desire to pay attention and interact with others, but poor frontal brain function hinders them from doing so.

Dyslexia or developmental reading disorder stands out as both often confused or mistaken for the other three disorders and for the lack of treatment options available to parents. Dyslexia falls under the category of academics. Although the other three disorders are sometimes challenging to differentiate, dyslexia deserves special attention.

The first disorder that is commonly confused with dyslexia is autism. Our office has evaluated dozens of children who were referred with a presumptive diagnosis of autism, only to find out they have dyslexia. These children often face social isolation due to their behavior problems, which are a result of their academic struggles. This isolation can occur both because schools isolate them due to their academic difficulties, and because the children isolate themselves due to the impact dyslexia has on their self-esteem. When a child is not performing well academically and has behavior problems, and the school is unsure about the cause, autism is often the diagnosis chosen for referral.

ADHD is another diagnosis that is frequently confused with dyslexia. Boys are often referred because they are disrupting the classroom, experiencing behavior problems at home and at school, and struggling academically. However, the underlying cause of their academic struggles is often not identified as a learning problem but rather attributed to attention and behavior problems. While boys are more commonly identified with ADHD than girls, they are usually treated with medication and/or counseling, and the underlying academic difficulty is largely ignored.

Some children exhibit symptoms of anxiety, which is entirely understandable given the impact of dyslexia on their academic performance. Unfortunately, this often results in dyslexia being overlooked as a diagnosis or listed as one of several issues, rather than being identified as the primary concern.

Despite affecting 15 to 20 percent of school-aged children, dyslexia is identified by schools only four percent of the time, if at all, and only a small number of those children receive tutoring services, though they often receive accommodations, such as more time for tests. During our Pediatric Grand Rounds presentation, we provided testing tools for primary care providers to determine if a child may have dyslexia.

The second significant challenge with dyslexia is the lack of available treatment services for low-income families. Only a few centers provide appropriate testing and tutoring, and they accept only private insurance, not Medicaid, which is the insurance most of our children have. Even with private insurance, these centers charge up to $200 for a diagnostic evaluation.

Our program recommends a more affordable tutoring system, while also recognizing many low-income families cannot even afford that. Furthermore, if one or both parents have dyslexia, which often occurs because it is a genetic disorder, they are unable to provide the recommended tutoring. If both parents work, it is also challenging for them to find time for tutoring.

Middle and upper-class students will always have an advantage over low-income students, with better schools and teachers in their neighborhoods, and their parents can afford tutoring for things like the SAT and advanced placement classes. While this may not change anytime soon, our society has an obligation to teach children how to read, which is basic and essential to their future success.

Although dyslexia is challenging to fix and expensive in our current system, the medical community must view it as a medical diagnosis and respond appropriately. Our Pediatric Grand Rounds presentation provided recommendations on how our hospital could provide appropriate services, and we welcome any comments or questions.