Definition

 Specific learning difficulties (SpLDs) stem from specific neurodevelopmental cognitive weaknesses.

 Some of these difficulties affect early learning: language, motor skills, etc.;

Others more specifically affect academic learning: written language, mathematics.

The term “SpLD” is a functional term that seeks to highlight the specific nature of these difficulties, which cannot be explained by a broader learning disability.

The difficulties that fall under this umbrella are classified according to an international system (DSM-5), under the following names:

• Specific learning difficulties:
  •  difficulty with reading (commonly known as dyslexia);
  • difficulty with writing (commonly known as dysorthographia);
  •  difficulty with mathematics (commonly known as dyscalculia);
• Language difficulty (commonly known as dysphasia);
• Developmental co-ordination disorder (commonly known as dyspraxia and including some forms of dysgraphia);
•  Attention deficit hyperactivity disorder (commonly known as ADHD)

DSM-5 defines specific learning difficulties as follows:

They are confirmed using standardised assessment tools highlighting scores below the normal level expected for the individual’s age;

They are specific, and cannot be entirely explained by another sensory (deafness, vision), neurological (innate or acquired brain damage), mental health or psychiatric (personality, emotional or behavioural development disorder) condition, or by a lack of socio-cultural support;

They are lasting, persisting for at least six months despite one-to-one support and targeted teaching strategies;

They will last throughout a person’s life.

They are present from the initial stages of development, but may appear later (when the child is no longer able to employ strategies to compensate for their difficulty or difficulties).

• They have a significant impact on success at school, ability to work or everyday activities.
• The diagnostic criteria for difficulties listed in DSM-5 do not prejudge changes over time (changes vary from one child to the next, and may lead to stabilisation, deterioration or improvement).

Epidemiology

Overall estimates drawn from international studies show that, together, the common learning difficulties affect around 8% of children in each age group. Experiencing more than one difficulty is common, and this contributes to delays in diagnosis, complications with treatment and a more serious prognosis.

Impact of learning difficulties

The impact of learning difficulties varies widely depending on:

•  the extent of the difficulties;
•  the nature of the difficulty or difficulties;
•  the possible presence of any comorbidities;
•  spontaneous development by the child of mitigation or circumvention strategies at the cognitive level;
•  changes brought about by educational support;
•  how early a diagnosis is made and treatments put in place;
•  monitoring of the care provided;
•  the environment and the quality of family support.

If the cognitive processes involved in learning are not automated, this causes attention overload, and the student is unable to access the “multitasking” aspect of any learning activity.

• Learning difficulties lead to slowness, fatigue and sometimes problems with organisation or behavioural difficulties. They may require accommodations and/or adaptations, or even compensation strategies in some cases.

Without a diagnosis and appropriate treatment, there is a risk:

•  Of falling behind or even failing at school, requiring specific educational measures:

 In the Principality, these measures are put in place by the school medical service (Medical Inspectorate for Schools/Department of Health Affairs), in conjunction with the Department of Education, Youth and Sport.

They include:

• An Individual Care Plan (PAI) and, in France, a Personal Support Plan (PAP).
• For situations where the learning difficulties are severe, other educational support and assistance measures are offered following an assessment by the Medical and Educational Committee.

These measures to compensate for learning difficulties range from the allocation of a special needs teaching assistant to placing the child in a special needs class with specialist teachers.

• For examinations such as the Brevet des Collèges and the various Baccalaureate general (equivalent of A-levels), technology and vocational examinations, as well as the CAP vocational training certificate, accommodations can be made on the basis of a request submitted to the Nice Educational Authority. The request is first reviewed by the Medical Inspectorate for Schools, which will decide whether or not to endorse it.
•  Of the emergence of secondary emotional difficulties: low self-esteem, anxiety, depression, lack of interest in or aversion to school, opposition, reactive aggression.
•  Of difficulties integrating into work and social settings. Whenever learning difficulties require the involvement of several professionals, families will need to deal with multiple treatments and work out how to coordinate them.

The treatment journey

1. The challenges of a tailored journey

The challenges are multiple:

 For patients:

•  Accessing early diagnosis of learning difficulties and treatment appropriate to the individual
•  Accessing education and subsequently training
•  Avoiding or limiting disability, being able to integrate into the school and then work environment, participating in society
•  Maintaining self-esteem, building psychosocial skills

 For families:

•  Ensuring consideration of their questions and expectations (particularly requests for care to be coordinated), involving them in planning care
•  Achieving an expected improvement in their knowledge and that of their children, with a view to involving them further in their care

 For professionals:

•  Improving practices with support for decision-making in the initial assessment and guidance on initial treatment
•  Clarifying the role of various stakeholders, particularly at the intermediate level (between first port of call and referral centres)
•  Improving knowledge and understanding of the role of other stakeholders

  2 - Treatments:

Treatment of learning difficulties in the Principality is based on:

• Early identification: teachers are in the front line for identifying significant learning difficulties in pupils, but the Medical Inspectorate for Schools carries out validated and standardised systematic screening assessments for all pupils in their first year of nursery school and again in their third year; assessment is subsequently available on request as needed.

Pupils are then referred at an early stage to healthcare professionals for additional assessments in line with their educational and clinical circumstances.

• Treatment may involve one or more professionals due to the multidisciplinary nature of diagnosing learning difficulties.
• These include:
  • Speech therapists
  • Psychomotor therapists
  • Occupational therapists
  • Psychologists and neuropsychologists
  • Child psychiatrists

In the Principality of Monaco, the Plati Centre, which incorporates the Day Therapy Activities Centre (CATTP), Learning Difficulties Assessment Centre (CDTA) and Medical Psychology Centre (CMP), can, through the specific unit of the CDTA, treat some or all of these difficulties, carrying out the initial investigations required to reach a diagnosis in the most complex cases (learning difficulties alongside comorbidities) as well as appropriate rehabilitation.

To conclude: 

F.A.Q:

Q: Who should I talk to if my child is having difficulty at school?

• Your regular family doctor or paediatrician: they will be able to refer you to the right professional depending on the difficulty, and will write a prescription for the assessment to be carried out
• The medical inspector for schools: they can make an appointment depending on whether you have already had assessments carried out or not, and refer you to a specific professional (speech therapist, occupational therapist, etc.) or to a more specialist centre such as the CDTA or CMP, or to the Language and Learning Difficulties Referral Centre (CRTLA) in Nice.

Q: My child has had assessments (speech and language, neuropsychological, etc.) and “needs help”. Who should I contact?

• The medical inspector for schools: this is the only person authorised to put in place educational support measures when a “specific learning difficulties” diagnosis is made; the medical inspector will get in touch with your child’s school.