Dement Neuropsychol 2012 March;6(1):18-28 Original Article

A model for pediatric and

neuropsychological screening assessment
of children with learning disabilities
Claudia Berlim de Mello1, Leila Raquel Russowsky Brunoni2, Ana Luiza Pilla3,
José Augusto Aguiar Carrazedo Taddei4, Thais Barbosa5, Elaine Girão Sinnes6, Camila Cruz Rodrigues7,
Monica Carolina Miranda8, Mauro Muzskat9, Orlando Francisco Amodeo Bueno10

ABSTRACT. Objectives: The high frequency of learning difficulties, attention disorders or developmental delay in children
in the early years of schooling has resulted in a greater demand for pediatric services. Such services generally include
assessments covering various specialties, are lengthy and often inaccessible to families due to prohibitively high cost. This
paper presents an economically efficient model of interdisciplinary diagnosis. Methods: A group of 109 Brazilian students
from public schools aged between 5 and 14 years old, referred by teachers for a history of learning disabilities, behavioral
changes or language problems, was evaluated at the NANI (Nucleo de Atendimento Neuropsicologico Infantil). Assessments
were performed simultaneously during a single day’s attendance and comprised clinical-genetic examination, behavioral
assessment and neuropsychological screening, specially developed for the process. The multiaxial system of DSM-IV
was adopted for diagnostic description. Results: The results revealed heterogeneity in diagnoses which included specific
learning disorders (25.7%), mild intellectual disabilities (17.43%), as well as suspected dysmorphic features (11.93%).
Logistic regression showed good sensitivity of neuropsychological screening in the detection of predictive factors for specific
developmental disorders, while working memory (p=0.05) and language (p=0.02) problems were found to be higher risk.
Conclusions: The model adopted proved to be useful for defining the diagnosis of several conditions in infancy, and can be
incorporated into specialized clinics such as psychiatric or developmental pediatric services.
Key words: neuropsychological screening, interdisciplinary assessment, children, primary care, DSM-IV.

MODELO DE TRIAGEM NEUROPSICOLÓGICA E PEDIÁTRICA PARA ESCOLARES COM DIFICULDADES DE APRENDIZAGEM

RESUMO. Objetivos: A alta frequência de dificuldades de aprendizagem, distúrbios atencionais ou atraso no desenvolvimento
cognitivo, em crianças nos primeiros anos de escolaridade, vem acarretando grande demanda por serviços de saúde.
Tais serviços em geral abrangem avaliações em diversas especialidades, realizadas em períodos de tempo prolongados,
frequentemente de pouca acessibilidade para as famílias devido ao alto custo. Neste trabalho apresenta-se um modelo de
diagnóstico interdisciplinar economicamente viável. Métodos: Foram avaliados os dados de um grupo de 109 alunos da
rede pública de ensino entre 5 e 14 anos de idade, encaminhadas ao NANI (Nucleo de Atendimento Neuropsicológico Infantil)
pelas professoras por apresentarem história de dificuldades de aprendizagem, alterações comportamentais ou problemas
de linguagem oral. As avaliações foram realizadas conjuntamente em um único dia de atendimento e abrangeram exame
clínico-genético, avaliação comportamental e uma triagem neuropsicológica qualitativa, especialmente desenvolvida para
o processo. Adotou-se o sistema multiaxial do DSM-IV na descrição diagnóstica. Resultados: Os resultados revelaram uma
heterogeneidade de diagnósticos, incluindo transtornos específicos de aprendizagem (25,7%), deficiência intelectual leve
(17,43%) e presença de dismorfias a esclarecer (11,93%). Análises de regressão logística evidenciaram boa sensibilidade
da triagem neuropsicológica na detecção de fatores preditivos para transtornos específicos do desenvolvimento, sendo que
problemas de memória operacional (p=0,05) e de linguagem (p=0.02) se evidenciaram como de maior risco. Conclusões:
O modelo adotado mostrou-se útil, assim, na delimitação diagnóstica de queixas de diversas condições na infância, podendo
ser incorporado em clínicas especializadas tais como psiquiátricas ou pediátricas.
Palavras-chave: rastreio neuropsicológico, interdisciplinaridade, crianças, serviços de saúde, DSM-IV.

1
Doutora, Núcleo de Atendimento Neuropsicológico Infantil, Centro Paulista de Neuropsicologia/AFIP. 2Médica, Centro de Genética Médica, Universidade Federal
de São Paulo (UNIFESP), São Paulo SP, Brazil. 3Médica, Centro de Genética Médica, UNIFESP. 4Professor Associado, Disciplina de Nutrologia do Departamento de
Pediatria, UNIFESP. 5Doutora, Núcleo de Atendimento Neuropsicológico Infantil, Centro Paulista de Neuropsicologia/AFIP. 6Mestranda, Departamento de Pediatria,
UNIFESP. 7Doutora, Núcleo de Atendimento Neuropsicológico Infantil, Centro Paulista de Neuropsicologia/AFIP. 8Doutora, Núcleo de Atendimento Neuropsicológico
Infantil, Centro Paulista de Neuropsicologia/AFIP. 9Doutor, Núcleo de Atendimento Neuropsicológico Infantil, Centro Paulista de Neuropsicologia/AFIP. 10Professor
Livre Docente, Departamento de Psicobiologia, UNIFESP.

Claudia Berlim de Mello. Centro Paulista de Neuropsicologia – Rua Embaú, 54 – 04039-060 São Paulo SP – Brazil. E-mail: [email protected]

Disclosure: The authors report no conflits of interest. Received August 23, 2011. Accepted in final form January 9, 2012.

18 Assessment of learning disabilities     Mello CB, et al.

 Dement Neuropsychol 2012 March;6(1):18-28 ■

INTRODUCTION chronic non-progressive encephalopathy in children and

C omplaints of learning difficulties, attention disor-

ders, or developmental delay constitute one of the
most frequent reasons for referral of children to pae-
genetic syndromes should be excluded. Possible comor-
bidities with other conditions, such as Attention Deficit
Hyperactivity Disorder (ADHD), Oppositional Defiant
diatric neurologists, psychologists or speech and lan- Disorder and Conduct Disorder must also be considered.
guage therapists. In most cases, referrals occur in the Therefore, diagnostic interdisciplinary models are
first few years of elementary school, when problems especially indicated for a global comprehension of learn-
during the literacy process arise or when children fail ing difficulties, essential for the planning of interven-
to reach the expected levels of academic achievement. tion programmes in educational and health contexts.
The impact that such difficulties can have on the child’s A neuropsychological approach in such models is also
development creates the need for accurate diagnosis, particularly important, as it involves the analysis of chil-
identification of specific educational demands, and fam- dren’s performance in complex cognitive functions such
ily support. At the same time, the multiple factors that as perception, attention, memory and language. The
may contribute to the onset of learning difficulties or results of analyses enable the identification of learn-
behavioural problems, including environmental (socio- ing difficulty subtypes associated with specific clinical,
economic, family-related) and neurobiological (clini- neuropsychological or psychosocial profiles, and can
cal, genetic) factors, also call for coordinated actions by therefore contribute to the definition of more refined
healthcare and educational teams. In summary, failing educational interventions. Also, questions concerning
in school raises questions concerning the integration familial, educational and social systems should also be
of multidisciplinary teams and the efficiency of assess- considered in the process of diagnostic investigation.
ment models for reaching a dynamic diagnosis and In this sense, the adoption of the DSM-IV Multiaxial
planning early intervention strategies. System seems particularly promising. It is a model for
The diagnosis based on poor academic performance clinical diagnosis, which consists of axes that are each
involves, primarily, the distinction between learning associated with different information domains, includ-
difficulties and actual disabilities.1-3 Learning difficul- ing psychosocial and environmental problems. Axis 1
ties may be caused by educational inadequacy, cir- describes actual clinical disorders, such as specific learn-
cumstantial family-related factors, socio-economic or ing disorders; Axis 2 describes intellectual deficiency;
affective-emotional problems, or can be secondary to Axis 3 comprises medical conditions associated with the
sensorial alterations, psychiatric disorders, intellectual main diagnosis, and Axis 4 describes psychosocial and
deficiency, and chronic or neurological diseases. Learn- environmental problems, such as those related to socio-
ing disabilities, however, according to the DSM-IV defi- economic conditions, which may interfere in the evolu-
nition,1 are diagnosed when the individual’s achievement tion of the disease.
on individually administered, standardized tests in reading, Therefore, the adequate diagnosis of learning disor-
mathematics, or written expression is substantially below ders depends on complex investigation procedures and
that expected for age, schooling, and level of intelligence. on the involvement of a specialised professional team.
Therefore, learning disabilities refer to lack of specific Generally, assessment procedures such as psychodiag-
reading, writing and mathematic abilities which are not nosis or neuropsychological examination are lengthy
compatible with the individual’s developmental level, and complex, and often become inaccessible to the low
intellectual capacity and schooling level, as a result of in- income population. Due to the high financial cost that
trinsic constitutional factors, probably of neurobiologi- it entails, the feasibility of traditional neuropsychologi-
cal origin.3,4 In Brazil, epidemiological data indicate that cal assessment in health units, with several individual
30% to 40% of children in early schooling years have meetings and the application of various tests and pro-
some type of learning difficulty, and 3% to 5% present cedures, has been questioned by some researchers from
disabilities.2 Other authors hold that the prevalence of the health care field, who emphasise the importance of
learning disabilities affects 5% to 10%, reaching levels an economically efficient evaluation model- a challenge
of up to 17%.5 for health units around the world.6
According to these distinctions, the clinical diagnosis In Brazil, neuropsychological screening procedures
for learning disabilities must be based on the results of have been developed aimed at speeding up diagnostic
intellectual and neuropsychological assessments, as well and intervention processes for patients with complaints
as on psychosocial and academic performance investi- of cognitive dysfunctions, such as the Mini-Mental Ex-
gations. Additionally, neurological problems such as amination7 and Neupsilin for adults.8 For children,

Mello CB, et al.     Assessment of learning disabilities 19

■ Dement Neuropsychol 2012 March;6(1):18-28

however, there are very few instruments of this nature dinators of each participating school also followed the
available, especially those incorporating an interdisci- groups.
plinary approach. At the first individual appointment with the profes-
The present study discusses the results of an in- sionals involved in the research, all procedures associ-
terdisciplinary diagnostic investigation conducted in ated with the diagnostic investigation were explained to
children with complaints of learning difficulties, from parents or main caregiver. Information concerning the
2005 through 2007, who were referred for assessment identification of the child’s main caregiver (e.g., biologi-
at the Núcleo de Atendimento Neuropsicológico Infan- cal mother, grandmother, step mother) and respective
til (NANI). The assessment involved a multidisciplinary schooling level (in years) was registered, with the objec-
team of health professionals, child neurologists, neuro- tive of understanding family conditions. The parent or
psychologists, speech and language therapists, paedia- main caregiver signed an informed consent agreement
tricians and clinical geneticists. authorising the child’s participation in the assessments.
Multidisciplinary assessment protocols, including Subsequently, an interdisciplinary assessment of the
clinical genetic examination and qualitative neuropsy- children was performed by a team of about seven pro-
chological screening, were especially created for use in fessionals from NANI (all experts in the adopted proce-
these children. The aim was to put together a screening dures) followed by meetings for analysis of results. The
model that simultaneously encompassed the needs of referred procedures were namely anamnesis and clinical
the children and families and also those of the teachers, genetic testing, qualitative neuropsychological screen-
seeking optimisation through an integrated team effort ing and finally, a behavioural investigation, amounting
in the diagnostic process, and that could also be incor- to 3.5 hours of overall assessment per child. All proce-
porated at a later stage into the public educational and dures are described in detail below.
health network. The team met on a daily basis at the end of the proce-
dures in order to discuss diagnostic hypotheses for the
METHODS four children seen on the day, based on DSM-IV’s cri-
Casuistic. The multidisciplinary diagnostic investigation teria and the multiaxial system. These meetings lasted
involved 109 children, predominantly males (66%), at- about two hours. At a later date, further meetings with
tending one of the first four years of Elementary School professionals (educational coordinators and teachers)
in one of São Paulo City’s municipalities. The mean age from the schools were held in order to present results
of children was 8 years and 7 months (SD 2.9). The chil- and put forward suggestions of interventions pertinent
dren were previously referred by their teachers because to each case.
of several complaints such as: (1) persistent difficul- Anamnesis and clinical genetic testing – In an ap-
ties reading and writing, not remedied by conventional pointment with one of the two paediatricians, a pre-
educational actions; (2) presence of substantial social tested and pre-coded questionnaire was used to collect
interaction difficulties or dysfunctional behaviour, such information from the caregiver through anamnesis
as negativity and aggressiveness, affecting the learning inquiring about previous and current clinical history,
process; and (3) considerable delay in speech develop- neuropsychomotor development, as well as gestational,
ment. Therefore, the children were identified within the perinatal and family history (blood relation of parents,
municipality’s educational network, which comprises a use of alcohol or drugs during pregnancy and child’s
population of around one million students in Elemen- birth conditions). Low birth weight (<2500g) and length
tary School (Education Secretariat of the Municipality of stay in hospital longer than three days (indicator of
of São Paulo; www.sp.gov.br accessed in 23/09/2009). birth complications) were recorded since they consti-
tute developmental risk factors. The neuropsychomotor
Procedures. Groups of four children along with their par- development investigation involved a questionnaire on
ents were referred to the unit for a day of screening. gait and speech acquisition, based on the Denver II de-
Hence, all procedures included in the interdisciplinary velopment scale adapted for the Brazilian population.9
diagnostic assessment were performed during one day The anamnesis was complemented by an inquiry
spent at the unit by each subject and his/her parent, into associated medical conditions (Axis 3 in DSM-IV
over a period of four hours with a lunch break. The pro- multiaxial system) including epilepsy, previous and cur-
cedures included appointments for clinical genetic test- rent diseases, and sensorial and motor deficiencies.
ing and neuropsychological screening. Education coor- After the anamnesis, clinical genetic testing includ-

20 Assessment of learning disabilities     Mello CB, et al.

 Dement Neuropsychol 2012 March;6(1):18-28 ■

ing anthropometric measurements (weight, height and For the investigation of visual spatial working mem-
cephalic perimeter) and physical examination was per- ory, a task consisting of a page with 5 randomly dis-
formed by a clinical genetician, paying special attention tributed blue squares against a white background was
to the presence of mild or severe dysmorphisms, aim- utilised. The child was asked to point at a sequence of 2
ing to identify phenotypes that suggested presence of and 3 squares initially presented by the examiner, first
a genetic syndrome. Additionally, the presence of signs in direct order and then in reverse order. An additional
of chronic non-progressive encephalopathy, such as gait page with numbers was used in order to help the exam-
alterations or spasticity, was investigated. The instru- iner point at the sequences (Appendix 1).
ment for anamnesis data collection and clinical genetic (D) Visual constructive skills: The visual construc-
testing was specifically developed for this purpose. tive skills task consisted of copying four simple shapes
Neuropsychological screening – Initially, a global in- (a T-shape, a circle, a cross and a rhombus), with per-
tellectual development assessment using Raven’s Col- formance assessed based on the Child Neurological Ex-
ored Matrices was carried out. For children older than amination.13 Based on these parameters, the adequate
12 years, an estimated IQ based on two tests from the reproduction of the first three figures is expected from
WISC-III scale (Cubes and Vocabulary) was used. Subse- children aged 5 to 6 years. The adequate reproduction of
quently, the simplified neuropsychological assessment the rhombus is expected from children from the age of
(screening), composed of qualitative and quantitative 7 upwards.
tests based on traditional neuropsychological tests was (E) Visual selective attention: Visual selective at-
conducted.10,11 tention skills were investigated by asking the children
The qualitative neuropsychological screening was to find 6 target figures – representing familiar objects
organised taking into consideration the child’s perfor- – in succession. The targets were displayed among 50
mance in specific functions. The selected tasks could be distracting figures, randomly distributed on a page with
quickly applied indistinctly by the health profession- a white background, and the maximum time allowed for
als for an initial screening result, thus minimising the their selection was 5 minutes.
examiner’s subjective perception of the child’s general (F) Language: Speech (articulation), verbal expres-
condition and cognitive performance. sion and verbal comprehension skills were examined in
The performance on each of the tasks was assessed the language assessment. Aspects of speech and verbal
qualitatively being scored as (0) when the child did not expression skills were analysed based on observations of
perform any of the task items adequately; (1) when the speech speed (normal, slow, accelerated); temporal logi-
child executed at least one of the task items adequately; cal speech sequence, and sentence structure (adequate;
(2) when all the items were executed adequately, as ex- alterations in sentence structure, such as agrammatical
pected for the particular age group. The skills investi- sentences). The investigation of comprehension skills
gated are described below. included analysis of children’s answers to questions
(A) Self care: Aspects related to self-care were as- presented by the examiner after the oral presentation
sessed in terms of the child’s independence for dressing, of a short story. For the assessment of expressive skills,
eating and hygiene. At ages of between 5 and 7 years, children were asked to tell a story based on the free
the child’s performance was considered adequate even drawings. Pragmatic aspects were investigated based
when there was a need for parental supervision in these on observations of the child’s performance during the
areas. From this age onwards, complete independence dialogue (visual contact; gestural communication; spon-
was expected. taneous participation and respec
(B) Drawings: The children were asked to perform Behavioural assessment – The assessment of behav-
free drawing, and performance assessed according to ioural issues was based on the Child Behavior Checklist
the evolution of the drawings produced.12 Hence, the – CBCL.14 For this assessment, the presence of behav-
presence of recognisable figures in the investigated ioural problems related to symptoms indicative of de-
sample, which involved the 5 to 14 year age group, was pression, anxiety, oppositional defiant disorder, conduct
expected from 5 years and up whereas complete scenes disorder and attention deficit disorder at a clinical level,
were expected from 7 years of age. contributed to the diagnosis of disorders diagnosed for
(C) Working memory: The investigation on verbal the first time during childhood (DSM-IV Axis 1).
working memory was based on oral repetition of se-
quences of 2 and 3 digits, initially in direct order and Statistical analysis. Logistic regression models were ad-
then in reverse order. justed using the Backward Stepwise Wald method.15

Mello CB, et al.     Assessment of learning disabilities 21

■ Dement Neuropsychol 2012 March;6(1):18-28

The dependent set of variables consisted of each of the Table 1. Demographic variables of the 109 children assessed.
two diagnostic axes expressed only by the positive (1) N %
or negative (2) diagnostic criterion. The independent Gender Female 36 33.03
set consisted of six measures (domains) derived from
Male 73 66.97
the neuropsychological screening: self-care, drawings,
Main Father and mother (biological) 40 36.70
working memory, visual construction, attention and
caregivers Mother alone 36 33.03
language. The measures (or domains) were also strati-
fied in a way that segmented the sample into either al- Grandmother 4 3.67
tered scores (lower than 2 in each of the six domains) Other conditions 23 21.10
or normal scores (higher than 2 in each of the six do- Education of Illiterate 7 6.42
mains). Based on the stratified data, odds ratios were caregivers Elementary school (not completed) 54 49.54
calculated for each of the six domains, according to the
Elementary school (completed) 9 8.26
presence or absence of positive diagnosis, for each of the
axes independently. The independent variables that had High school (not completed) 4 3.67
significant association with each of the axes separately High school (completed) 13 11.93
were verified.
Finally, the data concerning the percentage of right
answers for each axis based solely on the significant Table 2. Distribution of diagnoses according to DSM-IV Axes.
independent variables and with the presence of all in- N %
dependent variables (canonical correlation) is shown. Axis I No diagnosis or condition on Axis I 55 50.46
Also, the model adequacy indexes for each of the axes
Learning disorder NOS 14 12.84
were calculated.16 The level of significance adopted was
5% and the software programme utilised in statistical Disorder of written expression 14 12.84
treatment was SPSS 13.0. Attention-deficit/Hyperactivity disorder 4 3.67
Conduct disorder 10 9.17
RESULTS Oppositional defiant disorder 3 2.75
The assessment of family conditions indicated that Pervasive developmental disorder 9 8.26
the main caregivers in the investigated sample were
Axis II Normal intellectual functioning 44 40.37
predominantly biological parents or the mother alone.
More than half of the caregivers reported being either Borderline intellectual functioning 14 12.84
illiterate or not having concluded Primary School educa- Mild intellectual disability 19 17.43
tion (Table 1). Intellectual disability, severity unspecified 28 25.69
After the application of scales and diagnostic as- Axis III No diagnosis or condition on Axis III 82 75.23
sessments, the participants discussed possible diag- Presence of dysmorphic features (to clarify) 13 11.93
noses based on the four axes contained in the DSM-IV
Dysmorphic features (to clarify) with macrosomia 5 4.59
(Table 2).
Table 3 shows that the variables “working memory” Definitive diagnosis 9 8.26
and “language” were significant predictors of positive Axis IV No problems reported on Axis IV 64 58.72
diagnosis on Axis 1. This means the diagnosis for spe- Isolated problems 31 28.44
cific developmental disorders in early childhood was Multiple problems 14 12.84
associated with impairment in these tasks. Results in-
dicated that, of children with positive diagnosis on Axis
1, 77.8% showed working memory problems, while working memory tasks were found to be predictive of
55.6% showed language problems. Children with work- positive diagnosis for intellectual deficiency. Statistical
ing memory deficits appeared to be 5.3 times, and those analysis showed that the children with drawing prob-
with language delay 26.7 times, more likely to present a lems (87.7%) were 4.8 times more likely to present posi-
positive diagnosis on Axis 1 in comparison to children tive diagnosis on Axis 2 in comparison to children with
without these problems. The confidence intervals were no problems on this task (18.28%). On the other hand,
broad due to the low frequency of children without lan- good performance on working memory can be consid-
guage disorders in the investigated sample. ered a protective factor for problems on Axis 2. Children
On Axis 2, low performance on the drawing and with working memory problems (95%) were found to be

22 Assessment of learning disabilities     Mello CB, et al.

 Dement Neuropsychol 2012 March;6(1):18-28 ■

Table 3. Logistic regression (with frequencies) and odds ratio calculated for each of the six measures and significant association with diagnostic axes 1 and 2.
95% CI
% OR Lower Upper p
A1 – Clinical disordersa Self-care Atypical 74.10 1
Typical 54.40 0.25 0.02 3.8 0.32
Drawing Atypical 90.10 1
Typical 55.60 1.31 0.41 4.16 0.65
Working memory Atypical 77.80 1
Typical 14.54 5.35 1.99 28.95 0.05*
Visual constructive skills Atypical 64.80 1
Typical 87.30 0.18 0.02 1.6 0.12
Attention Atypical 50.00 1
Typical 72.70 1.19 0.18 8.01 0.86
Language Atypical 55.60 1
Typical 3.60 26.78 1.87 383.93 0.02*
A2 – Intellectual disability b
Measures
Self-Care Atypical 43.10 1
Typical 56.90 20.76 0.49 875.76 0.11
Drawing Atypical 87.70 1
Typical 18.28 4.8 1.9 25.73 0.05*
Working memory Atypical 25.00 3.8 1.6 4.9 0.01*
Typical 95 1
Visual constructive skills Atypical 90.80 1
Typical 54.50 0.23 0.05 1.15 0.07
Attention Atypical 76.90 1
Typical 61.40 0.52 0.1 2.79 0.44
Language Atypical 92.30 1.74 1.02 4.06 0.04*
Typical 52.30 1
Hit rate: 62% – canonical correlation 91%; Hit rate: 79.8% – canonical correlation 95%; *Significant differences at level p<0.05.
a b

4 times more likely to present positive diagnosis on Axis positive diagnosis on Axes 1 and 2 of DSM-IV, rendering
2 in comparison to children who did not have working it a valid preliminary diagnostic procedure for learning
memory problems (25.4%). However, children with lan- difficulties, with consistent application for the identifi-
guage problems were 1.74 times more likely to present cation of children with higher risk of specific disorders.
positive diagnosis on Axis 2. Thus, the neuropsychological screening model was
Considering each model individually gives a correct analysed in relation to its diagnostic capacity, based
answer rate of 79.8% (Axis 2) to 84.4% (Axis 1) for lo- on the statistical analyses described. The researchers
gistic models compared to real data. The Cox & Snell in- propose that this screening model be applied by duly
dex of logistic model adequacy for Axes 1 and 2 was 0.25 trained health or education professionals, requiring
(Axis 1) and 0.31 (Axis 2), indicating a low proportion an application time of approximately 1.5 hours, as the
of variance explained by the model. This means that first stage in the screening of children with learning dif-
the model created cannot be utilised directly due to its ficulties in case of early referral for a more conventional
reduced capacity to explain real data. It is noteworthy and in-depth diagnostic investigation. Table 4 provides
however that this neuropsychological screening model a comparison of aspects of the procedures as well as
is composed of sensitive attributes for the detection of the execution time of the interdisciplinary assess-

Mello CB, et al.     Assessment of learning disabilities 23

■ Dement Neuropsychol 2012 March;6(1):18-28

Table 4. Comparison of procedures and durations of interdisciplinary assessment model and qualitative neuropsychological screening.
Interdisciplinary assessment Neuropsychological screening
Anamnesis: 30 minutes Anamnesis: 30 minutes
Professional required: pediatrician Professional required: health professional
Pediatric examination: anthropometric measurements and clinical testing Qualitative neuropsychological screening (30 minutes) (Appendix 1)
(20 minutes)
Genetic examination: Presence of dysmorphisms; phenotypes (20 minutes) Low performance on >4 tasks – referral for neurological and
neuropsychological assessment (10 minutes)
Intellectual assessment: Raven; estimated IQ (20 minutes) Clinical report (20 minutes)
Professional required: psychologist
Neuropsychological evaluation: qualitative neuropsychological screening –––
(30 minutes) (Appendix 1)
Professional required: interdisciplinary team
Tests scores – neuropsychological and behavioral evaluations (30 minutes) –––
Professional required: member of interdisciplinary team
Convening of multidisciplinary teams to establish diagnosis (15 minutes) –––
Clinical report (30 minutes) –––
Professional required: member of interdisciplinary team
Duration: 3 hours and 30 minutes Duration: 1 hour and 30 minutes
Number of professionals required: 7 Number of professionals required: 1 (previously trained health professional)

ment model versus the qualitative neuropsychological model adopted in these cases, however, allowed the ob-
screening. servation of some neuropsychological variables which
proved sensitive for the detection of diagnoses on Axes
DISCUSSION 1 and 2 of DSM-IV, including conduct and oppositional
The main objective of this article was to describe a defiant disorders, invasive developmental disorders and
model of a diagnostic investigation conducted among specific learning disabilities, such as dyslexia. Some rec-
children with learning difficulties, referred by their ommendations for the use of this model are therefore
teachers to a specialised service dealing with neuro- necessary.
developmental disorders, based on an interdisciplin- The results of the statistical analysis pointed to
ary diagnostic investigation especially developed for the importance of the neuropsychological assessment
these children. The diagnostic model included clinical screening being applied in its entirety, as the perfor-
genetic testing, behavioural assessment and screening mance variables identified as significant were not suf-
of neuropsychological functions, in conjunction with ficiently predictive of diagnosis on Axes 1 and 2. This
conventional cognitive measures – estimated IQ and means that although it might be possible to consider
Raven’s Colored Matrices. Although screening measures the use of the cited neuropsychological variables alone
and measures with qualitative characteristics have less (working memory and language), found to be sensitive
specificity compared to complete neuropsychological for the diagnosis on Axis 1, the percentage of correct
tests, our results indicated that these procedures are a answers in this case was only 62%. When all the tasks
valuable tool for intervention in terms of providing fast were applied and considered as a group in the multivari-
early detection, cost and accessibility.6 Screening tests able approach (canonical correlation), the percentage of
may have low specificity, raising the need for analysis right answers increased to 91%. For the diagnoses on
of incongruence and internal coherence level between Axis 2, when taking into consideration only the 3 sig-
variables, which are important for accurate diagnosis. nificant variables (drawings, working memory and lan-
The same holds regarding the use of estimated measures guage), the percentage was 79.8%. On the other hand,
for global intellectual performance, as well as scales that the application of all procedures resulted in a percentage
prioritise only one cognitive domain (as occurs with Ra- of right answers above 95% for the same Axis.
ven’s test, which focuses on non-verbal cognition). The We observed a percentage of right answers for diag-

24 Assessment of learning disabilities     Mello CB, et al.

 Dement Neuropsychol 2012 March;6(1):18-28 ■

noses on Axes 1 and 2 in about 75% when a low perfor- though logistic regression analyses did not identify a di-
mance was identified in five of the adopted tasks; 60% rect association between socio-environmental variables
when identified in four tasks; 45% when identified in and diagnoses on Axes 1 and 2, previous studies suggest
three tasks; 30% when identified in two tasks; and 15% that the impact these factors may have on children’s
when identified in only one task. Thus, considering the development should not be underestimated.25,26 It has
performance on one task only would increase the risk been claimed, for instance, that environmental factors
of error in the diagnosis of 85% of the cases. Conse- such as low income, families with a high number of chil-
quently, the recommendation for the identification of dren, single parenting, maternal depression, paternal
children with a history of learning difficulties in need absence, low parental educational level or psychiatric
of referral for a more comprehensive neurological and problems are as relevant as biological risk factors, such
neuropsychological assessment, based on the adopted as low birth weight and malnutrition, for the develop-
model, would be that of identifying a low performance ment and mental health of children. Evidence indicates
on a minimum of 4 out the 6 adopted tasks. that favourable socio-demographic conditions and qual-
The findings concerning the sensitivity of the neu- ity of environmental stimulation are associated with a
ropsychological screening model for diagnoses on Axes higher level of social competence as well as lower rates
1 and 2 have theoretical support from the literature of psychiatric morbidity.27,28 As a result of these aspects,
on Cognitive Neuropsychology. Working memory is a it has been proposed that investigations into family
short-term memory system, which involves temporary structure and dynamics become an increasingly present
maintenance and mental manipulation of information, component in clinical assessments.29 Hence, the DSM-
either of verbal or visual spatial nature, and is highly as- IV multiaxial system can contribute substantially to dif-
sociated with attention and executive functions.17 Ver- ferential diagnosis in learning difficulties, and to a more
bal working memory, for instance, is involved in reading in-depth understanding of cases on an individual basis.
and writing skills and its dysfunctions are evidenced in To conclude, this article presented a diagnostic in-
dyslexia.4,18-21 The relationship between working mem- vestigation model of an interdisciplinary approach
ory and academic performance has also been noted.22 based on qualitative procedures for neuropsychological
The importance of language, in turn, can be analysed if assessment, which constitutes preliminary actions for
taking into consideration both its communication and differentiation between learning difficulties and dis-
instrumental functions in relation to thought and cog- abilities. We also propose the use of neuropsychologi-
nition organisation, as sustained by the socio-historical cal screening indistinctively by professionals from sev-
conceptions of development.23 Finally, drawing involves eral health areas. We are aware of the need to test this
an integration of visual constructive and praxical func- screening model in larger samples and to train health
tions, and is also regulated by language and thought.24 and education professionals on its use and on the DSM-
Together, these three cognitive skills or functions IV multiaxial diagnostic system. However, models with
showed a higher rate of right answers for diagnosis on such characteristics that can be incorporated into pub-
Axis 2 – which concerns the presence of intellectual de- lic health services could prove useful for health centers
ficiency – in comparison to Axis 1. throughout Brazil.
One final consideration concerns the recorded ob-
servations on Axes 3 and 4. Medical conditions associ- Financial support. AFIP (Associação Fundo de Incentivo a
ated with the main diagnoses identified in cases partici- Psicofarmacologia). A AFIP (www.afip.com.br) is a non-
pating in this study included, for instance, malnutrition, profit private entity founded in the 1970s by health
epilepsy and dental occlusion disorders, among others, care professionals, professors of the Psychobiology De-
which imply a demand for differentiated medical refer- partment of the Escola Paulista de Medicina (Paulista
rals. The presence of problems associated with Axis 4 Medical School currently UNIFESP), with the objective
was identified in 41.28% of the families. These problems of providing financial support for teaching activities,
included, for instance, parents’ alcoholism (detected in scientific research and medical care for the community,
23% of cases) and exposure to domestic violence. Al- with emphasis on public health services.

Mello CB, et al.     Assessment of learning disabilities 25

■ Dement Neuropsychol 2012 March;6(1):18-28

REFERENCES
1. American Psychiatric Association. Manual diagnóstico e estatístico de 17. Hitch GJ, Towse JN, Hutton U. What limits children’s working memory
transtornos mentais. 4 ed. Texto revisado DSM-IV-TR. Porto Alegre: span? Theoretical accounts and applications for scholastic develop-
Artmed; 2002. ment. J Exp Psychol Gen 2001;130:184-198.
2. Ciasca SM. Distúrbios de aprendizagem: proposta de avaliação inter- 18. Bishop DVM, Adams C. A prospective study of the relationship between
disciplinar. São Paulo: Casa do Psicólogo; 2003. specific language impairment, phonological disorders and reading retar-
3. Fletcher JM, Coulter WA, Reschly DJ, Vaughn S. Alternative approach- dation. J Child Psychol Psychiatry 1990;31:1027-1050.
es to the definition and identification of learning disabilities: some ques- 19. Gerber A. Problemas de aprendizagem relacionados à linguagem: sua
tions and answers. Ann Dyslexia 2004;54:304-331. natureza e tratamento. Porto Alegre: Artes Médicas; 1996.
4. Kavale KA, Forness SR. What definitions of learning disability say and 20. Barbosa T. Memória operacional fonológica, consciência fonológica e
don’t say: a critical analysis. J Learn Disabil 2000;33:239-256. linguagem nas dificuldades de alfabetização. Dissertação apresentada
5. Lagae L. Learning disabilities: definitions, epidemiology, diagnosis and para a obtenção do título de Mestre em Ciências - Departamento de
intervention strategies. Pediatr Clin North Am 2008;55:1259-1268. Psicobiologia, Universidade Federal de São Paulo. São Paulo, 2005.
6. Carey PF, Konkol RJ. Neuropsychology: adaptation for a busy pediatric 21. Cappelini S, Ciasca SM. Avaliação da consciência fonológica em crian-
neurology clinic in a managed care setting. Presented in part at the ças com distúrbio específico de leitura e escrita e distúrbio de apren-
Thirtieth National Meeting of the Child Neurology Society, Victoria BC, dizagem. Temas Desenvolv 2000;8:17-23
2001:17-20. 22. Gathercole SE, Alloway TP. Working memory and classroom learning.
7. Brucki SMD, Nitrini R, Caramelli P, Bertolucci PHF, Okamoto IH. Sug- Professional association for teachers of students with specific learning
estões para o uso do Mini-Exame do Estado Mental no Brasil. Arq Neu- difficulties, 2004;17:2-12.
ropsiquiatr 2003;61:777-781. 23. Vygostky LS. A formação social da mente. São Paulo: Martins Fontes;
8. Fonseca RP, Salles JF, Parente MAMP. Development and content valid- 1989
ity of the Brazilian Brief Neuropsychological Assessment Battery Neup- 24. Luria AR. Fundamentos de neuropsicologia. São Paulo: Ed. E.P.U.;
silin. Psychol Neurosc 2008;1:55-62 1986.
9. Frankenburg WF, Dodds J, Archer P, et al. Manual Denver, CO. Denver 25. Seifer R, Sameroff AJ, Dickstein S, Keitner G, Miller Y, Rasmussen S.
Developmental Materials, 1990. Parental psychopatology, multiple contextual risks, and one-year out-
10. Lezak M, Howieson DB, Loring DW Neuropsychological assessment. (4 comes in children. J Clin Child Psychol 1996;25:423-435.
ed). New York: Oxford University Press, 2004. 26. Sameroff AJ, Seifer R, Baldwin A, Baldwin C. Stability of intelligence
11. Spreen O, Strauss E. A compendium of neuropsychological tests. 2 ed. from preschool to adolescence: the influence of social and family risk
New York: Oxford University Press; 1998. factors. Child Dev 1993;64:80-97.
12. Meredieu, F. O Desenho infantil. São Paulo: CULTRIX; 1979:116 27. Martins M, Costa J, Saforcada E, Cunha M. Qualidade do ambiente e
13. Lefèvre A. B. Exame neurológico evolutivo. São Paulo, Sarvier; 1972 fatores associados: um estudo em crianças de Pelotas, Rio Grande do
14. Achenbach, TM. Manual for the Child Behavior Checklist/4-18 and Sul, Brasil. Cad Saúde Pública 2004;20:710-718
1991 Profile. Burlington, VT: University of Vermont, Department of Psy- 28. Bastos A, Urpia A, Pinho L, Filho N. O impacto do ambiente familiar nos
chiatry; 1991 primeiros anos de vida: um estudo com adolescentes de uma invasão
15. Hair J, Black W, Tatham J. Análise multivariada de dados. Editora Book- de Salvador (Bahia). Estud Psicol (Natal), 1999;4:239-271.
man; 2006. 29. Belsky J, Garduque L, Herneir E. Assessing performance, competence
16. Cox DR; Snell EJ. A general definition of residuals. J Royal Statist Soc and executive capacity infant play: relations to home environment and
1968;39:248-275. security of attachment. Dev Psychol 1984;20:406-417.

26 Assessment of learning disabilities     Mello CB, et al.

 Dement Neuropsychol 2012 March;6(1):18-28 ■

APPENDIX 1 – NEUROPSYCHOLOGICAL SCREENING

Identification
N°_____ Name: ______________________________________________________ Date of birth _____/_____/_____; School grade ________

Mother’s name: ___________________________________________________________ Mother’s educational level: ____________________

Clinical conditions
Delivery: Normal _______________ / Cesarean ______________ ; Birthweight: ________________ ; Hospital stay (days) ______________

Current weight: ____________________  Current height ______________________  Cephalic perimeter _____________________

Presence of dysmorphisms: minor ____________  major ____________ (number)

Skill/ Tasks Performance Observations

CLASSIFICATION
1. Squiggly lines __________
Drawing

2. Cells __________

3. First figures that arise from cells __________

4. Recognizable and well-structured figures __________

5. Complete scene __________

COPYING OF SIMPLE SHAPES

Visual constructive

1. T __________
skills

2. ● __________

3. + __________

4. ◊ __________

PRAGMATIC ASPECTS

1. Maintain eye contact in communication __________

2. Starts conversation spontaneously or communicates by gestures __________

3. Answers appropriately to what is requested __________

VERBAL EXPRESSION

1. Normal speed of speech __________

2. Good articulation skills __________

Sprache

3. Appropriate temporal sequence of speech __________

4. Vocabulary typical of age __________

5. Appropriate sentence structure __________

VERBAL COMPREHENSION

Story comprehension

Story: “Two boys were playing ball. One of them kicked the ball high, the ball hit the vase, the

vase fell and broke. When their mother arrived, she was very angry.” __________

Question: “Why was the mother angry?” __________

Mello CB, et al.     Assessment of learning disabilities 27

■ Dement Neuropsychol 2012 March;6(1):18-28

FINDING FIGURES

1. Horse __________

2. Scissors __________
Attention

3. Strawberry __________

4. Airplane __________

5. Cup __________

6. Pineapple __________

VERBAL

Oral repetition of digits

a) Forwards: 2-9-5 __________

b) Forwards: 3-1-8-5 __________

c) Backwards: 8-1-6 __________

Working memory

d) Backwards: 4-8-3-7 __________

VISUAL

Pointing at squares

a) Forwards: 1-5-3 3 __________

1 3
b) Forwards: 2-1-4 2 __________

c) Backwards: 5-3-2-1 5 __________

d) Backwards: 4-3-2-5 __________

Food __________
Self care

Clothing __________

Hygiene __________

Intellectual performance:

- IQ __________; Raven’s Colored Matrices: ________ (percentile)

Qualitative analysis of performance

– Drawing (0) / (1) / (2);
– Visual Constructive Skills (0) / (1) / (2);
– Language (0) / (1) / (2);
– Attention (0) / (1) / (2);
– Working memory (0) / (1) / (2);
– Self-care (0) / (1) / (2);

Number of well-developed skills (typical for chronological age):_______

Future referrals required

– Medical examination: pediatric / genetic
– Full neuropsychological assessment

Examiner: _______________________ Screening date:________

28 Assessment of learning disabilities     Mello CB, et al.