Is There Uniformity in the Diagnosis of Learning Disability Globally?

Learning disabilities (LDs) are a group of neurodevelopmental deficits that negatively affect the acquisition, organization, retention, comprehension, or application of age appropriate knowledge. Persons with LD lead a subsidized quality of life, especially in academic/vocational and psychosocial domains. A certificate issued by the medical boards at a state or district level is required to avail benefits such as scribes or relaxations. This may be done through a series of assessments by psychologists, special educators, or other health-care professionals. The authors aim to understand if uniformity exists in the assessment methods used for the diagnosis of LD globally and to prepare a gap analysis for the same. A systematic review was performed on English literature articles published from January 2005 to August 2023. Full-text studies reporting assessment and diagnostic methods of LD were included. A total of 1246 records were identified through a manual search of an electronic database. Seven duplicates were removed and 1174 studies were excluded based on the relevance by screening titles, abstracts, and full texts. Sixty-five studies were included and analyzed. The authors found a lack of uniformity in this diagnostic protocol, leading to uncertainty in disability certification, doctor shopping, and additional stress for the patients, as well as added burden on the government. Identification of LD requires a multistep assessment process with culturally relevant tools and norms and the participation of a multidisciplinary team of experts.

Diagnostic overshadowing: self-injurious behaviour as a manifestation of pain in the head and neck.

In the healthcare domain, diagnostic overshadowing is a concerning issue involving the erroneous attribution of physical symptoms to a patient's mental health, behavioural intricacies, or pre-existing disabilities. Individuals facing learning and communication challenges are particularly susceptible to this phenomenon, struggling to articulate or comprehend their experienced symptoms. Likewise, patients with autism spectrum disorder can have an escalated risk due to possible challenges in interpreting bodily cues. This article delves into the specialised care required for individuals with learning disabilities and/or autism, highlighting the pervasive risk of diagnostic overshadowing and the potential manifestation of pain as self-injurious behaviour in these patient groups. By underscoring the need to mitigate diagnostic overshadowing within dental practice, we advocate for reasonable adjustments in care delivery and comprehensive education of the dental team. Proficient tools for pain assessment and effective communication are emphasised to collectively improve the healthcare experience for these vulnerable patient cohorts.

Learning difficulties often not documented in newly diagnosed focal epilepsy.

OBJECTIVE: A previous investigation of people with newly diagnosed focal epilepsy participating in the Human Epilepsy Project 1 (HEP1) revealed an association between learning difficulties and structural brain differences, suggesting an underlying relationship prior to seizure onset. To investigate physicians' practices of documentation learning difficulties during clinical encounters, we conducted a review of initial epileptologist encounter notes from HEP1 participants who self-reported early life learning difficulties separately as part of study enrollment. METHODS: HEP1 enrolled 67 North American participants between June 2012 and November 2017 who self-reported one or more difficulties with learning (i.e., having repeated grade, receiving learning support/remediation, and/or formal diagnosis of a learning disability) prior to epilepsy diagnosis as part of the study enrollment. The epileptologist's initial encounter note was then reviewed in detail for each of these participants. Documentation of learning issues and specific diagnoses of learning disabilities was compared to participant characteristics. Regression analysis was used to test for any independent associations between participant characteristics and physician documentation of learning difficulties. RESULTS: There were significant independent relationships between age, sex, and physician documentation of learning difficulties. On average, participants ages 22 and younger were 12.12 times more likely to have their learning difficulties documented compared to those 23 years and older (95 % CI: 2.226 to 66.02, p = 0.004). Additionally, male participants had 7.2 times greater odds of having their learning difficulty documented compared to female participants (95 % CI: 1.538 to 33.717, p = 0.012). There were no significant independent associations between race, language, employment, or geographical region. SIGNIFICANCE: These findings highlight disparities in physician documentation for people with newly diagnosed focal epilepsy and a history of learning difficulties. In the HEP1 cohort, physicians were more likely to document learning difficulties in males and in younger individuals. Systematic practice standards are important for reducing healthcare disparities across populations, improving clinical care to individuals, as well as enabling more accurate retrospective study of clinical phenomenon.

The development of number line estimation in children at risk of mathematics learning difficulties: A longitudinal study.

Children with mathematics learning difficulties (MLD) show poorer performance on the number line task, but how performance on this task relates to other mathematical skills is unclear. This study examined the association between performance on the number line task and mathematical skills during the first 2 years of school for children at risk of MLD. Children (N = 100; Mage = 83.63 months) were assessed on four occasions on the number line task and other mathematical skills (math fluency, numerical operations, and mathematical reasoning). Estimation patterns were analyzed based on the representational shift and proportional judgment accounts separately. More consistent longitudinal trends and stronger evidence for differences in mathematical skills based on estimation patterns were found within the representational shift account. Latent growth curve models showed accuracy on the number line task as a predictor of growth in some mathematical skills assessed. We discuss impacts of methodological limitations on the study of estimation patterns.

Symptoms of Cognitive Impairment Among Children With Atopic Dermatitis.

Importance: Previous studies suggest that atopic dermatitis (AD) is associated with cognitive impairment in children, but these studies have relied primarily on neurodevelopmental diagnoses (rather than symptoms) as proxy measures of cognitive function. It remains unknown if certain subpopulations of children with AD are at greater risk of cognitive impairment. Objective: To examine the association of AD with symptoms of cognitive impairment (difficulty in learning or memory) among US children and whether this association varies according to the presence or absence of neurodevelopmental comorbidities (attention-deficit/hyperactivity disorder [ADHD], developmental delay, or learning disability). Design, Setting, and Participants: This cross-sectional study used 2021 data from the US National Health Interview Survey collected on children aged 17 years or younger without intellectual disability or autism. The presence of AD was based on a parent or adult caregiver's report indicating either a current diagnosis of AD or a previous medical confirmation of AD by a health care professional. Main Outcomes and Measures: Difficulty with learning or memory as reported by the child's caregiver. Results: Among the weighted total of 69 732 807 participants, 9 223 013 (13.2%) had AD. Compared with children without AD, children with AD were more likely to experience difficulties with learning (10.8% [95% CI, 7.8%-15.8%] vs 5.9% [95% CI, 5.1%-6.9%]; P < .001) and difficulties with memory (11.1% [95% CI, 8.0%-15.9%] vs 5.8% [95% CI, 4.9%-6.9%]; P < .001). In multivariable logistic regression models adjusted for sociodemographic factors, asthma, food allergies, and seasonal allergies or hay fever, AD was associated with increased odds of difficulties in learning (adjusted odds ratio [AOR], 1.77; 95% CI, 1.28-2.45) and memory (AOR, 1.69; 95% CI, 1.19-2.41). In analyses stratified by neurodevelopmental comorbidities, AD was associated with 2- to 3-fold greater odds of memory difficulties among children with any neurodevelopmental disorder (AOR, 2.26; 95% CI, 1.43-3.57), including ADHD (AOR, 2.90; 95% CI, 1.60-5.24) or learning disabilities (AOR, 2.04; 95% CI, 1.04-4.00). However, AD was not associated with learning or memory difficulties among children without neurodevelopmental conditions. Conclusions and Relevance: Results of this cross-sectional study suggest that pediatric AD was generally associated with greater odds of reported difficulties in learning and memory. However, this association was primarily limited to children with neurodevelopmental comorbidities, such as ADHD or learning disabilities. These findings may improve the risk stratification of children with AD for cognitive impairments and suggest that evaluation for cognitive difficulties should be prioritized among children with AD and neurodevelopmental disorders.

Health inequalities for people with learning disabilities: why it matters and what emergency physicians need to know.

People with learning disabilities die on average 16 years earlier than the general population in England. They are a vulnerable group and may have unhealthy lifestyles and multimorbidity that lead to poor health outcomes. Worryingly, premature deaths are also more common and these often have contributory healthcare causes. This may be a result of staff lacking awareness, expertise and experience managing people with learning disabilities, the lack of reasonable adjustments, or discriminatory attitudes. Other issues include polypharmacy and inappropriate prescribing of sedatives, inappropriate use of do not resuscitate orders, and diagnostic overshadowing leading to delayed or misdiagnoses. Emergency physicians need to be aware of subtle or atypical presentations of illnesses such as sepsis. Carers and family can be vital informants, helping clinicians to interpret subtle signs and aid communication with people with learning disabilities. One simple approach to reasonable adjustments, as required by law, is the TEACH mnemonic: people with learning disabilities need more time (T), in a conducive environment (E), with clinicians approaching them with the right attitude (A) and an open mind. Good communication (C) is essential and clinicians must make every attempt to understand their patients and to be understood by their patients. Finally clinicians need to consider what 'help' (H) the patient and their carers or family needs. With the right approach, time and environment, emergency physicians can optimise the care delivered to people with learning disabilities to address their needs.

Screening for depression: Psychometric properties of the German version of the Glasgow depression scale for people with a learning disability (individual and carer version).

BACKGROUND: Adults with intellectual disabilities should participate in the diagnostics of their mental health. The Glasgow Depression Scale for people with a Learning Disability (GDS-LD) and its Carer Supplement (GDS-CS) were translated into German and tested. METHODS: Internal consistency, criterion validity and inter-test reliability were tested in 64 adults with borderline, mild or moderate intellectual disabilities and their carers. Convergent validity was analysed in 57 adults without intellectual disabilities. RESULTS: Internal consistency was good (α = 0.81) for GDS-LD and acceptable (α = 0.72) for GDS-CS. The GDS-LD did not differentiate between groups with and without depression. The GDS-CS significantly differentiated between these groups. Convergent validity of the GDS-LD was high. The correlation of GDS-LD and GDS-CS was non-significant. CONCLUSIONS: In its present form the German version of the GDS-LD does not meet the psychometric properties to be used in clinical practice. This leads to the broader question, how to measure depression in people with learning disabilities with the knowledge of the fallibility of existing measures when utilised with this clinical cohort. Also, future studies need to investigate the role of self-rating.

A Register Study Suggesting Homotypic and Heterotypic Comorbidity Among Individuals With Learning Disabilities.

The present study examined whether learning disabilities (LD) in reading and/or math (i.e., reading disability [RD], math disability [MD], and RD+MD) co-occur with other diagnoses. The data comprised a clinical sample (n = 430) with LD identified in childhood and a sample of matched controls (n = 2,140). Their medical diagnoses (according to the International Classification of Diseases nosology) until adulthood (20-39 years) were analyzed. The co-occurrence of LD with neurodevelopmental disorders was considered a homotypic comorbidity, and co-occurrence with disorders or diseases from the other diagnostic categories (i.e., mental and behavioral disorders, diseases of the nervous system, injuries, other medical or physical diagnoses) was considered a heterotypic comorbidity. Both homotypic and heterotypic comorbidity were more common in the LD group. Co-occurring neurodevelopmental disorders were the most prominent comorbid disorders, but mental and behavioral disorders, diseases of the nervous system, and injuries were also pronounced in the LD group. Accumulation of diagnoses across the diagnostic categories was more common in the LD group. No differences were found among the RD, MD, and RD+MD subgroups. The findings are relevant from the theoretical perspective, as well as for clinical and educational practice, as they provide understanding regarding individual distress and guiding for the planning of support.

Assessment of Specific Learning Disabilities and Intellectual Disabilities.

We review literature related to the assessment and identification of Specific Learning Disabilities (SLD) and Intellectual Disabilities (ID). SLD and ID are the only two disorders requiring psychometric test performance for identification within the group of neurodevelopmental disorders in Diagnostic and Statistical Manual - 5. SLD and ID are considered exclusionary of one another, but the processes for assessment and identification of each disorder vary. There is controversy about the identification and assessment methods for SLD, with little consensus. Unlike ID, SLD is weakly related to full-scale IQ, and there is insufficient evidence that the routine assessment of IQ or cognitive skills adds value to SLD identification and treatment. We have proposed a hybrid method based on the assessment of low achievement with norm-referenced tests, instructional response, and other disorders and contextual factors that may be comorbid or contraindicative of SLD. In contrast to SLD, there is strong consensus for a three-prong definition for the identification and assessment of ID: (a) significantly subaverage IQ, (b) adaptive behavior deficits that interfere with independent living in the community, and (c) age of onset in the developmental period. For both SLD and ID, we identify areas of controversy and best practices for identification and assessment.

Using the learning disability screening questionnaire to help identify people with an intellectual disability in homeless services.

BACKGROUND: We explored the accuracy of using the learning disability screening questionnaire (LDSQ) in services for people experiencing homelessness in the United Kingdom. METHOD: We examined the concordance between the LDSQ outcomes and assessments of intellectual disability. Seventy adults experiencing homelessness completed the LDSQ. Staff completed the LDSQ and a measure of adaptive functioning for 38 of this group. Nine participants received an intellectual assessment. RESULTS: Sensitivity and specificity for the LDSQ when completed by staff was 83% and 96% respectively and 50% and 92% when completed by the individual. Seven people had intellectual and adaptive functioning in the intellectual disability range. CONCLUSION: The results suggest that the LDSQ would be an appropriate and beneficial screening tool to use within services for people experiencing homelessness. More accurate results would be likely if it were completed by staff.

An investigation into the factor structure of the Health of the Nation Outcome Scales for People with Learning Disabilities.

BACKGROUND: The Health of the Nation Outcome Scales for People with Learning Disabilities (HoNOS-LD) is one of the most used outcome measures in learning disability services in the United Kingdom. There is relatively little known of the psychometric properties of the scales. METHOD: A data set of HoNOS-LD scales from 571 people with learning disabilities was randomly split into two halves. Exploratory Mokken analysis was applied to the first dataset, and confirmatory scale factor analysis was applied to the second dataset to test the fit of scale structures. RESULTS: Two-factor and three-factor solutions were explored in the Mokken analysis, with the three-factor option having somewhat better characteristics. One-factor, three-factor and seven-factor solutions were explored using confirmatory factor analysis; a three-factor solution with items 8, 16, 17 and 18 used separately offers the best characteristics. CONCLUSIONS: The HoNOS-LD is best conceptualised as consisting of three scales, accounting for 14 items that can be labelled as 'Cognitive and Physical Functioning', 'Behaviour and Mood Disturbances' and 'Functional Difficulties'.

Prevalence and Trends in Diagnosed Learning Disability Among US Children and Adolescents From 1997 to 2021.

This cross-sectional study uses data from the National Health Interview Survey to examine the prevalence of and trends in diagnosed learning disability among US children and adolescents from 1997 to 2021.

How Do Intermediate Grade Students With and Without Language-Based Learning Disabilities Use Noun Phrases in Narrative Writing?

PURPOSE: Noun phrase usage and elaboration is an important feature of literate language. In this study, we described noun phrase usage and elaboration in the narrative writing samples of intermediate grade students with and without language-based learning disabilities. METHOD: Narrative writing samples from 64 students in fourth through sixth grades were coded for five types of noun phrases using coding procedures adapted from prior research. Noun phrase ratios (NPR) were calculated for each type of noun phrase evaluated in the study. NPRs represented the proportion of noun phrases to total clauses produced in the sample. RESULTS: Students in this study included all five types of noun phrases in their narrative writing to varying degrees. Between-group differences were observed in the frequency of complex noun phrase usage. Significant relationships between NPRs, analytic writing measures, and a standardized reading measure were observed. CONCLUSIONS: Noun phrase usage is an important consideration for both theoretical and clinical purposes. Findings from this study are related to theoretical models of writing and levels of language frameworks. The clinical relevance for noun phrase assessment and intervention for intermediate grade students with language-based learning disability is discussed.

Trajectory assessments of cognitive, visuospatial, and academic profile in nonverbal learning disability (visuospatial developmental disorder).

Substantial progress has been made in defining children with nonverbal learning disability (NLD), but longitudinal studies are still lacking. To start filling this gap, we examined changes in general cognitive functioning, visuo-constructive skills, and academic profiles in a group of children with NLD, also taking into account any internalizing and externalizing symptom as transdiagnostic features. A total of 30 participants (24 boys) diagnosed with NLD were tested twice, with a three-year gap between the two assessments (T1: at age 8-13; T2: at 11-16), on their cognitive profile, visuospatial abilities, and academic performance (i.e., reading, writing and arithmetic abilities). At T2, any internalizing and externalizing symptom was also investigated. Statistically significant differences emerged between the two assessments in terms of the WISC-IV Perceptual Reasoning Index (PRI), handwriting speed and arithmetical fact retrieval. The NLD profile seems to be characterized by a relative stability in its core features during a child's development, as regards both weaknesses (i.e., visuospatial processing) and strengths (i.e., verbal abilities). The presence of internalizing and externalizing symptoms also suggested the importance to analyze transdiagnostic features rather than only sharp boundaries between conditions.

Review and update of the Health of the Nation Outcome Scales for People with Learning Disabilities (HoNOS-LD).

BACKGROUND: The Health of the Nation Outcomes Scales for people with Learning Disabilities (HoNOS-LD) is an 18-item measure which provides a structured and standardized approach to rating various clinical and psychosocial outcomes and has been in use nationally since 2002. AIMS: To revise and improve the HoNOS-LD's utility in contemporary intellectual disability (ID) services whilst retaining its original objectives and five-point severity ratings. METHOD: ID clinicians were invited to complete an online survey, rating each item on the existing measure for being fit for purpose, identifying issues and suggesting improvements based on their experience of using the HoNOS-LD in practice. Scales were then assessed and revised sequentially; survey responses were used to inform discussion and revisions to the HoNOS-LD by the Advisory Board. RESULTS: A total of 75 individuals replied. Respondents had used HoNOS-LD for an average of 8.0 years (S.D. 5.28 years) and 88% found the scale to be useful in their practice. On average, respondents used HoNOS-LD ratings to inform care 42.4% of the time (S.D. 33.5%). For each scale there was a significant negative correlation between the percentage of positive/very positive respondent ratings and the number of changes proposed. Common changes included simplifying terms, reducing ambiguity and replacing anachronistic language. CONCLUSION: The changes outlined in this paper are based on the advisory group's expert consensus. These changes are intended to improve reliability and validity but now need empirical testing as well as review by service users.

[Cognitive disorders in children with dyscalculia]. / Kognitivnye narusheniya u detei s diskal'kuliei.

OBJECTIVE: This study was to study the features of cognitive disorders in children with dyscalculia. MATERIAL AND METHODS: The main study group included 48 children aged 8 to 10 years with manifestations of dyscalculia. The control group consisted of 30 children aged 8 to 10 years without manifestations of learning disabilities and other neuropsychiatric disorders. The following research methods were used in the work: the SNAP-IY scale for assessing concomitant manifestations of attention deficit hyperactivity disorder, the L.D. Malkova, «Working memory¼ technique for the quantitative assessment of working memory, TOVA computer test for the quantitative assessment of attention disorders and impulsiveness. RESULTS: The study showed that only in 4 cases (8.3%) dyscalculia was of an isolated nature, without concomitant neuropsychiatric disorders. Most often, manifestations of attention deficit hyperactivity disorder (ADHD) were recorded in children with dyscalculia - 33 (68.8%) children and manifestations of other learning disorders (dyslexia - 27 (56.3%) children, dysgraphia - 22 (45.8%) children). In 20 (41.7%) cases, children in the study group had asthenic symptoms. When comparing the results of working memory testing in the study group, the number of correct answers was significantly lower than in the control group. Indicators of the TOVA psychophysiological test in children with dyscalculia showed a statistically significant increase in the number of inattention errors both in the first and second half of the test, compared with children from the control group. CONCLUSION: Thus, dyscalculia should be considered not only as a disorder of arithmetic skills, but also as a disorder based on multiple cognitive dysfunctions, such as working memory dysfunction, dysfunction of attention.

Early diagnosis of the learning disabilities in kids using a computer game-based solution.

PURPOSE: Learning disabilities or learning disorders are umbrella terms used for wide variety of learning problems like Dyslexia, Dyscalculia, Dysgraphia, and Dyspraxia. These disabilities are due to the neurological disorders which affects brain functions. Early diagnosis of these disabilities in kids from age 3 to 6 will help to start early medical treatments and get them back to the normal condition. MATERIAL AND METHOD: we developed a software-based Learning Disability Evaluation Kit called YALU with computer Game Modules for kids targeting their learning disabilities. These Computer game-based modules of the YALU consist of different tasks for the different age levels to identify the symptoms of the disabilities mentioned above. The children's interaction results to each task of the game modules with the answers of the questioner about the children given by the parents will be evaluated with the threshold values given by a panel of consultant psychologist and paediatrician of the normal kids to identify the learning disabilities in kids aged 3-6 years. The result will be given to the respective parties and uploaded to the Website under the child's name. RESULT: YALU has been tested using 50 students in age 3-5 in three preschools. The teachers have identified Fourteen students with some learning disability symptoms. Using YALU, twelve out of fourteen students had been clearly identified. Hence, the YALU Evaluation Kit to have an accuracy 85% in diagnosing the right disability. However, the accuracy could be increased with the accurate assessments of the parents about their kids.IMPLICATIONS FOR REHABILITATIONLearning disabilities are neurological disorders that affect the brain's ability to receive, process, store, respond to and communicate information; and there are four types (Dyslexia, Dyspraxia, Dysgraphia and Dyscalculia)In this paper, we present the extracted computational techniques targeting the Dyslexia, Dyspraxia, Dysgraphia and Dyscalculia and developed a software application (YALU Learning Disability Evaluation Kit) which consists of computer game modules for the kids for evaluation their learning disabilities.The developed game modules can screen the learning disabilities and these gamification modules (YALU) consists of tasks which are based on symptoms of the said disabilities. The outcomes of each module is evaluated these learning disabilities in kids age from 3 years to 6 years by analysing children's interactions to the each tasks, the child condition and then compare the result with the threshold values of the normal kids given by consultant psychologist and paediatrician.

What Skills Could Distinguish Developmental Dyscalculia and Typically Developing Children: Evidence From a 2-Year Longitudinal Screening.

Developmental dyscalculia (DD) is a mathematics learning disorder that affects approximately 5% to 7% of the population. This study aimed to detect the underlying domain-specific and domain-general differences between DD and typically developing (TD) children. We recruited 9-year-old primary school children to form the DD group via a 2-year longitudinal screening process. In total, 75 DD children were screened from 1,657 children after the one-time screening, and 13 DD children were screened from 1,317 children through a consecutive 2-year longitudinal screening. In total, 13 experimental tasks were administered to assess their cognitive abilities to test the domain-specific magnitude representation hypothesis (including symbolic and nonsymbolic magnitude comparisons) and four alternative domain-general hypotheses (including working memory, executive function, attention, and visuospatial processing). The DD group had worse performance than the TD group on the number sense task, finger sense task, shifting task, and one-back task after both one-time and two-time screening. Logistic regressions further indicated the differences on the shifting task and the nonsymbolic magnitude comparison task could distinguish DD and TD children. Our findings suggest that domain-specific nonsymbolic magnitude representation and domain-general executive function both contribute to DD. Thus, both domain-specific and domain-general abilities will be necessary to investigate and to intervene in DD groups in the future.

Subtypes of mathematical learning disability and their antecedents: A cognitive diagnostic approach.

Using cognitive diagnostic modeling (CDM), this study identified subtypes of mathematics learning disability (MLD) based on children's numerical skills and examined the language and spatial precursors of these subtypes. Participants were 99 MLD children and 420 low achievers identified from 1839 Finnish children (966 boys) who were followed from preschool (age 6) to fourth grade (2007-2011). Five subtypes were identified: the arithmetic fluency deficit only subtype, the counting deficit subtype, the pervasive deficit subtype, the symbolic deficit subtype, and the counting and concept deficit subtype. Different subtypes depended on different constellations of language and spatial deficits. Findings highlight the effectiveness of CDM in identifying MLD subtypes and underscore the importance of understanding the specific deficits and antecedents of the subtypes.

Barriers to Identifying Learning Disabilities: A Qualitative Study of Clinicians and Educators.

OBJECTIVE: The estimated prevalence of learning disabilities (LDs) is nearly 8% of all children. Fewer than 5% of all children are diagnosed in public schools, jeopardizing remediation. We aimed to identify barriers affecting front-line child-facing professionals in detecting LDs in school-aged children. METHODS: We conducted a qualitative study with individual interviews of 40 professionals from different areas of the United States identified through theoretical sampling (20 educators, 10 pediatricians, and 10 child mental health clinicians). Clinicians represented academic and community settings, and educators represented public, private, and charter schools. Twenty had expertise in assessing LDs; 20 were generalists without specific training. We also endeavored to maximize representation across age, gender, race and ethnicity, and location. We analyzed transcripts utilizing grounded theory and identified themes reflecting barriers to detection. RESULTS: Themes and sub-themes included: 1) areas requiring improved professional education (misconceptions that may hinder detection, confounding factors that may mask LDs, and need for increasing engagement of parents or guardians in identifying LDs) and 2) systemic barriers (time constraints that limited professionals' ability to advocate for children and to delve into their emotional experiences, inconsistent guidelines across institutions and inconsistent perceptions of professional responsibility for detection, and confusion surrounding screening tools and lack of screening by some professionals in the absence of overt problems). CONCLUSIONS: Clinicians and other child-facing professionals may benefit from augmented training in screening and identification and enhanced evidence-based and institutional guidance. These efforts could increase efficiency and perceived responsibility for recognition and improve earlier detection.