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The pandemic has disrupted academic progress and children with learning disabilities in particular have been impacted. Here is what pediatricians should know to help support literacy and recognize dyslexia.
JK is an 8-year-old boy who is struggling in school. Now in second grade, JK started kindergarten during the COVID-19 pandemic. JK attended first grade virtually, which was difficult. The transition to in-person learning has helped, but JK is still behind in reading. JK’s parent wonders: Is it hyperactivity/attention-deficit disorder (ADHD)? Would medication help? Should he repeat a grade? Or just hope that third grade goes better?
The dilemma faced by JK, his family, and his pediatrician is an increasingly common one made only more complicated by the COVID-19 pandemic. In part, the effects of COVID-19, with its disruptions to the educational system and to the lives of children and their families, amplify the drumbeat that educators have been making for some time: Let’s provide children with the help they need when they need it. Enter the Multi-Tier System of Supports, or MTSS.
Educational supports: an introduction to MTSS
In many ways, MTSS embodies the foundational tenets of pediatrics: prevention, early identification, and timely access to intervention. The MTSS approach aims to identify children who may need additional academic or behavioral supports, provides a certain level of support to all children, and tailors additional supports and intervention at an intensity that matches the child’s need(s). For the purposes of this article, the focus will be primarily on the academic aspects of MTSS, and specifically those that affect children with reading difficulties. The academic aspects of MTSS are sometimes referred to as response to intervention, or RTI, a term that reflects the importance of monitoring process. The behavioral aspects of MTSS, often referred to as positive behavioral interventions and supports, or PBIS, won’t be covered in depth in this article. (For more information on the behavioral aspects of MTSS, see https://mtss4success.org/resource/integrating-SEL-within-MTSS.)
MTSS provides 3 levels of intervention: tier 1 (universal) interventions that are available to all children; tier 2 interventions that are intensive, individualized supports, and often provided in a small group setting; and tier 3 interventions that are more intensive and individualized and may include referral for consideration of special education services.1 Foundational aspects of the model include:
Through universal screening, schools can identify children who would benefit from additional help and intervene without having to enter the process for consideration of special education services, which can be lengthy. MTSS also avoids inadvertent labeling of children experiencing learning difficulties due to other factors (eg, economic hardship, absenteeism, cultural factors, etc) as having a disability. Federal regulations provide states and local school districts with a substantial amount of flexibility when implementing MTSS to ensure that programming and intervention can be tailored to the needs of their communities.1 Critics of the model point out the need for timeliness in the monitoring phase to avoid students spending too long in a lower-level intervention.2
How are learning disabilities diagnosed?
Historically, school systems and psychologists have often identified a child as having a specific learning disability (SLD) when a significant discrepancy between the child’s intellectual ability (measured by intelligence testing, or IQ) and academic achievement (measured by achievement testing) was present. Often called the “discrepancy model,” this model had its flaws. In many cases, psychological testing did not occur until third or fourth grade and after the child had struggled for a few grades. Critics suggested that this model waited for the child to fail before providing help. In addition, the model may not be statistically valid for children with different types of cognitive profiles.3
Starting in 2004, the Individuals with Disabilities Education Act (IDEA) specified that states could no longer require schools to use the discrepancy model when identifying children in need of special education services. It provided schools with the flexibility to use RTI as well as other alternative research-based process in determining the need for special education services. As specified by IDEA, a student should be considered for SLD determination when they are failing to meet age or grade-level state expectations despite the presence of appropriate instruction and in absence of other causes.4 See Table 1 for full description of SLD determination. SLD in reading is also referred to as dyslexia.
In 2015, the Every Student Succeeds Act (ESSA), which replaced the No Child Left Behind Act of 2001, provided more flexibility to states and school districts while providing protections to economically disadvantaged students, students with disabilities, and English language learners.5 This type of flexibility is designed to allow states and schools to better tailor intervention to the unique needs of their communities6, which will be especially important as schools tackle the effects COVID-19.
Regardless of how dyslexia is defined or identified, the core features remain the same. Children with dyslexia struggle with phonemic awareness and processing. That is, they have difficulties recognizing how letter symbols translate into specific sounds that form the building blocks of words and sentences. This can result in difficulties with reading and decoding words, with spelling, and with reading comprehension. These difficulties are typically out of proportion with the child’s overall cognitive level. Children with a history of language delay may also be at increased risk for dyslexia.
How COVID-19 has affected learning to read
Research to determine how COVID-19 has affected learning is ongoing. Early studies suggest that academic progress declined by the end of the 2020-21 school year compared with previous years by 8 to 12 percentile points in math and 3 to 6 percentile points in reading.7 These effects are not universal: Students in earlier grades,7 students in economically disadvantaged schools, and students of color (eg, Black, LatinX, and American Indian and Alaska Native)8 seem to be disproportionally affected.8,9 In part, these disparities likely represent the significant challenges schools and communities faced in scaling up high-quality instruction during disruptions caused by COVID-19. Interestingly, implementation of remote learning does not completely explain differences in the degree of learning loss experienced by certain students and schools,9 which also suggests the importance of other sociodemographic factors.
Given these changes in performance, schools will need to determine how children with SLD are identified going forward. It seems likely that a larger number of children will qualify for MTSS services, but additional questions remain. For example, should lower age/grade norms be used for reference? And if so, what should those norms be, given disparities described above? Flexibilities built into ESSA and IDEA should ideally allow for these types of considerations.
The role of the pediatrician in promoting literacy skills
Encouraging families to read with young children and provide exposure to language and book promotes foundational reading skills. Pediatricians can check in with their patients and families about early literacy skills at health supervision visits, or when concerns about development or learning arise. Dyslexia also runs in families, so taking a good family history is important. See Table 2 for possible signs of dyslexia that pediatricians can use as a part of the surveillance process.
Intervention for dyslexia often occurs in the school setting, and pediatricians can play a role in advocacy. Tutoring outside school may be an option for some families, but relying on tutoring alone can further exacerbate inequities related to socioeconomic factors. Given the flexibility states and school systems have in implementing IDEA and ESSA, pediatricians can work with local school districts to understand their current processes. Pediatricians can also encourage parents and caregivers to work with their children to practice reading skills and, most importantly, to help make reading fun. See Table 3 for ways to promote reading skills at home. Practice and repetition are important for children with reading difficulties, but understandably these children may resist practicing something that is inherently difficult. Children with dyslexia are at increased risk for co-occurring emotional/behavioral conditions, including anxiety, depression, and ADHD. In general, individuals with reading difficulties are at risk for poorer health and vocational outcomes, so early identification and intervention are especially important.11
Closing the Loop
Getting back to our case, JK’s pediatrician can obtain a bit more history about the nature of his reading difficulties and provide advice to his family to contact the school about his progress. JK may already be receiving MTSS support or it may be time for his family to request an evaluation for SLD. Being able to help JK’s family navigate this process is time well spent.
Learning Disabilities Association: https://ldaamerica.org/
LD Online: https://www.ldonline.org/
Rebecca Baum is a developmental behavioral pediatrician and clinical professor of pediatrics at the University of North Carolina School of Medicine in Chapel Hill, and a member of the Contemporary Pediatrics® Editorial Advisory Board.