main alert for the important treatable organic disease processes that may very rarely show up with school failure and hyperactivity. Examples from our own relatively recent experience at Children's Hospital Medical Center in Boston include a child with hyperthyroidism as well as one with brain tumor. He must be prepared to care for the concomitant sympto¬ matic problems of seizure disorders or juvenile migraine and its variants, both of which are most frequent in this group of children. Finally, it is only the physician who can supervise pharmacotherapy, which is so fre¬ quently useful in reducing hyper¬ activity and thereby improving at¬ tention span. In fact, it is follow-up of drug ther¬ apy that places him in an excellent position to review the efforts of the educator and other professionals as they come to grips with the major problem of management of the edu¬ cational process per se. The physician can and should act as coordinator and moderator to stimulate schools to ac¬ tion where indifference has been the approach, and occasionally to moder¬ ate overenthusiastic efforts that are misguided and themselves causing psychological stresses and strains. CHARLES F. BARLOW, MD Department of Neurology Children's Hospital Medical Center 300 Longwood Ave Boston, MA 02115
Reply Sir.\p=m-\Dr.Newton's comments are well thought out and obviously based on experience. Our article was not intended to imply, as he suggests, "that we do not need to do a neurological examination of the child involved." Rather it suggests that a de-emphasis may be in order, ie, that a neurological examination need not be in the first phase of the evaluative process in a nonresearch setting. Certainly a
multidisciplinary approach to underachieving children is desirable; unfortunately the supply of "knowledgeable physicians" (primarily neurologists and selected pediatricians) is not plentiful in most areas.
Those who are available often lack either the time or inclination to assimilate and explain the psychoeducational data to parents. Most school districts have the option of dealing with the primary physician or em-
ploying neurological consultants. The going rate for neurological evaluation ranges from $45 to $60. In terms of educational outcome for the child, the cost/benefit ratio has not been acceptable in our school district. Each professional must make a similar
value
judgment based on available data, personal philosophy, and the re¬ sources in his/her community. Hope¬ fully, future studies will clarify the most effective type of physician/ educator alliance. RICHARD M. ADAMS, MD Southwestern Medical School School Health Services Dallas Independent School District 3700 Ross Ave Dallas, TX 75204
Neurological Signs in Learning-Disabled Children
Soft
and Controls
Sir.\p=m-\Thearticle by Adams et al, which appeared in the November 1974 issue of the Journal (128:614, 1974), compares the frequency of certain "soft" neurological signs in normal, borderline, and learning-disabled children. Their findings suggest that the presence of soft neurological signs is of little diagnostic usefulness in the examination of learning-disabled children. However, their selection of patients and, more specifically, their definitional criteria for learning-disabled children open to question the validity of the conclusion reached by the study. In defining the learning-disabled group of children, the authors utilized the lowest of three scores (reading, spelling, or arithmetic) on the Metropolitan Achievement Test after computing Myklebust Learning Quo-
tients for the subjects. Their definition yielded a sample of learning\x=req-\ disabled children that was greater than the number of normal children. Should one assume that the incidence of learning disabilities is 38% in the Dallas and Irving Independent school districts? A number of factors could have depressed the achievement scores in the learning-disabled group of children: low socioeconomic class, emotional factors, low average or bor¬ derline intelligence, lack of sleep the night before the tests, etc. The reader is not provided with comparison of mean
intelligence quotient
scores or
socioeconomic class between the nor¬ mal and the learning-disabled chil¬ dren in order to ascertain the equiv-
alency of both populations. Obviously, the conclusions of the study would not be valid if the sample of learning-dis¬ abled children included normal chil¬ dren whose achievement scores were depressed for reasons other than
learning disabilities. In their discussion, the authors cor¬ rectly exclude from their conclusions
children with the hyperkinetic syn¬ drome. Unfortunately, some learningdisabled children have short atten¬ tion spans, decreased concentrating ability, and easy distractibility, but show not overt signs of behavioral disorders. These children would prob¬ ably be classified by many as being hyperkinetic, and often exhibit soft neurological signs. Because in many instances teachers and parents do not complain of behavioral difficulties in such children, the syndrome might go unrecognized unless the physician identifies the soft neurological signs and subsequently alerts the school
psychologist to perform more specific psychometric tests. We are presently accumulating data on children with
behavioral disorders who exhibit substantial underachievement in school associated with distractibility, short attention span, and poor con¬ centrating ability. Preliminary data point to a strong correlation between the presence of soft neurological signs on the initial medical eval¬ uation and subsequent positive re¬ sponse to stimulant drugs. Therefore, the presence of soft neurological signs in some learning-disabled chil¬ dren may be of more than academic interest. ROBERT J. LERER, MD Butler County Diagnostic Center for Developmental Disorders PAMELA B. LERER, MA no
Mercy Hospital
Hughes Memorial Hospital Center Hamilton, OH 45011
Fort Hamilton
Reply Sir.\p=m-\Theconcern Dr. and Ms. Lerer show over the 38% incidence of learning-disabled children in our sample arises from the assumption that the sample was randomly selected. The "18 research classrooms" referred to in our article were each composed of approximately 50% learning-disabled and 50% randomly selected students, with the former previously identified for placement by screening instruments. We believed it
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Reply Sir.\p=m-\Dr.Newton's comments are well thought out and obviously based on experience. Our article was not intended to imply, as he suggests, "that we do not need to do a neurological examination of the child involved." Rather it suggests that a de-emphasis may be in order, ie, that a neurological examination need not be in the first phase of the evaluative process in a nonresearch setting. Certainly a
multidisciplinary approach to underachieving children is desirable; unfortunately the supply of "knowledgeable physicians" (primarily neurologists and selected pediatricians) is not plentiful in most areas.
Those who are available often lack either the time or inclination to assimilate and explain the psychoeducational data to parents. Most school districts have the option of dealing with the primary physician or em-
ploying neurological consultants. The going rate for neurological evaluation ranges from $45 to $60. In terms of educational outcome for the child, the cost/benefit ratio has not been acceptable in our school district. Each professional must make a similar
value
judgment based on available data, personal philosophy, and the re¬ sources in his/her community. Hope¬ fully, future studies will clarify the most effective type of physician/ educator alliance. RICHARD M. ADAMS, MD Southwestern Medical School School Health Services Dallas Independent School District 3700 Ross Ave Dallas, TX 75204
Neurological Signs in Learning-Disabled Children
Soft
and Controls
Sir.\p=m-\Thearticle by Adams et al, which appeared in the November 1974 issue of the Journal (128:614, 1974), compares the frequency of certain "soft" neurological signs in normal, borderline, and learning-disabled children. Their findings suggest that the presence of soft neurological signs is of little diagnostic usefulness in the examination of learning-disabled children. However, their selection of patients and, more specifically, their definitional criteria for learning-disabled children open to question the validity of the conclusion reached by the study. In defining the learning-disabled group of children, the authors utilized the lowest of three scores (reading, spelling, or arithmetic) on the Metropolitan Achievement Test after computing Myklebust Learning Quo-
tients for the subjects. Their definition yielded a sample of learning\x=req-\ disabled children that was greater than the number of normal children. Should one assume that the incidence of learning disabilities is 38% in the Dallas and Irving Independent school districts? A number of factors could have depressed the achievement scores in the learning-disabled group of children: low socioeconomic class, emotional factors, low average or bor¬ derline intelligence, lack of sleep the night before the tests, etc. The reader is not provided with comparison of mean
intelligence quotient
scores or
socioeconomic class between the nor¬ mal and the learning-disabled chil¬ dren in order to ascertain the equiv-
alency of both populations. Obviously, the conclusions of the study would not be valid if the sample of learning-dis¬ abled children included normal chil¬ dren whose achievement scores were depressed for reasons other than
learning disabilities. In their discussion, the authors cor¬ rectly exclude from their conclusions
children with the hyperkinetic syn¬ drome. Unfortunately, some learningdisabled children have short atten¬ tion spans, decreased concentrating ability, and easy distractibility, but show not overt signs of behavioral disorders. These children would prob¬ ably be classified by many as being hyperkinetic, and often exhibit soft neurological signs. Because in many instances teachers and parents do not complain of behavioral difficulties in such children, the syndrome might go unrecognized unless the physician identifies the soft neurological signs and subsequently alerts the school
psychologist to perform more specific psychometric tests. We are presently accumulating data on children with
behavioral disorders who exhibit substantial underachievement in school associated with distractibility, short attention span, and poor con¬ centrating ability. Preliminary data point to a strong correlation between the presence of soft neurological signs on the initial medical eval¬ uation and subsequent positive re¬ sponse to stimulant drugs. Therefore, the presence of soft neurological signs in some learning-disabled chil¬ dren may be of more than academic interest. ROBERT J. LERER, MD Butler County Diagnostic Center for Developmental Disorders PAMELA B. LERER, MA no
Mercy Hospital
Hughes Memorial Hospital Center Hamilton, OH 45011
Fort Hamilton
Reply Sir.\p=m-\Theconcern Dr. and Ms. Lerer show over the 38% incidence of learning-disabled children in our sample arises from the assumption that the sample was randomly selected. The "18 research classrooms" referred to in our article were each composed of approximately 50% learning-disabled and 50% randomly selected students, with the former previously identified for placement by screening instruments. We believed it
Downloaded From: http://archpedi.jamanetwork.com/ by a Karolinska Institutet University Library User on 05/23/2015
