Important aspects of the examination of a child with learning difficulty

Examination feature	Potential clinical implication
General observations and appearance
Sadness, anxiety, attention span, impulsivity, activity	Emotional or behavioral problems may affect learning
Ability to communicate and respond to instructions	Measure of language skills other than phonologic processing
Stigmata of genetic syndromes or prenatal exposures	May suggest a genetic syndrome or prenatal exposure. As examples: Down syndrome: Upslanting palpebral fissures, epicanthic folds, brachycephaly Fetal alcohol spectrum disorder: Short palpebral fissures, thin vermillion border, smooth philtrum Fragile X syndrome: Narrow face, large jaw, long prominent ears, large testes (after puberty) Klinefelter syndrome: Tall stature, small testes Turner syndrome: Short stature, webbed neck, micrognathia, short metacarpals, nail dysplasia, widely spaced nipples
Growth parameters
Head circumference, height, and weight	Growth parameters outside the ranges expected for age may indicate need for further evaluation. As examples: Head circumference or height and weight <10^th percentile may suggest fetal alcohol syndrome Children with fragile X syndrome usually have head circumference >50^th percentilile Short stature is a feature of Turner syndrome Tall stature is a feature of Klinefelter syndrome
Skin
Café-au-lait spots, ash leaf spots, adenoma sebaceum	Neurocutaneous disorders (eg, neurofibromatosis, tuberous sclerosis) are associated with learning problems
Genitalia
Delayed sexual maturation	May be associated with Turner syndrome, Klinefelter syndrome
Small testes	Suggestive of Klinefelter syndrome
Large testes (after puberty)	Suggestive of fragile X syndrome
Sensory screening
Hearing assessment	Hearing impairment may affect learning
Vision assessment	Vision impairment may affect learning
Neurologic examination
Asymmetry, increased or decreased muscle tone	Cerebral palsy
Coordination problems	Developmental coordination disorder
Weakness	Muscular dystrophy
Tics	Tourette syndrome
Staring episodes	Seizure disorder

Learning difficulty should be suspected or anticipated in children with any of the conditions in the table. Although the physical examination is an important component of the evaluation of children with developmental delays or learning difficulties, most children with learning difficulty have a normal physical examination. Learning difficulty at school is rarely the first manifestation of the conditions listed in the table.

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Important aspects of the examination of a child with learning difficulty