A school-aged child with delayed reading skills

CASE. During a health supervision visit, the father of a 7.5-year-old Afric an American second-grader asked about his son's progress in reading. He was concerned when, at a recent teacher-parent conference to review Darren's p rogress, the teacher remarked that Darren was not keeping up with reading s kills compared with others in his class. She said that he had difficulty so unding out some words correctly. In addition, he could not recall words he had read the day before. The teacher commented that Darren was a gregarious , friendly child with better-than-average verbal communication skills. His achievement at math was age-appropriate; spelling, however, was difficult f or Darren, with many deleted letters and reversals of written letters. A focused history did not reveal any risk factors for a learning problem in the prenatal or perinatal periods. Early motor, language, and social miles tones were achieved on time. Darren had not experienced any head injury, lo ss of consciousness, or chronic medical illness. He had several friends, an d his father denied any behavioral problems at home or at school. His teach er completed a DSM-IV-specific behavioral survey for attention-deficit/hype ractivity disorder (ADHD). It did not show any evidence of ADHD. Darren's f ather completed 1 year of college and is currently the manager of a neighbo rhood convenience store. His mother had a high school education; she recall ed that she found it difficult to complete assignments that required readin g or writing. She is employed as a waitress. Darren does not have any sibli ngs. The pediatrician performed a complete physical examination, the results of which were normal, including visual acuity, audiometry, and a neurological examination. It was noted that Darren seemed to pause several times in resp onse to questions or commands. On two occasions, during finger-nose testing and a request to assess tandem gait, directions required repetition. Overa ll, he was pleasant and seemed to enjoy the visit. His pediatrician concluded that he had a learning problem but she was uncer tain about the next step. She asked herself, "Is there anything else I can do in the office to evaluate Darren's problem with learning? Should I quick ly refer him for educational testing or encourage a reading tutor? What que stions can I ask his teacher that would be helpful? Am I missing a medical disorder?".