learning disorder/dyslexia/specific learning disorders

LEARNING DISABILITIESEMERGING TRENDS

Dr. Pawan Sharma

[email protected]

• Evolution of concept

• Concept and approaches

• Epidemiology

• Pathophysiology

• Assessment and Management

• Prognosis

• Issues Indian Context

• Conclusion

EVOLUTION OF CONCEPT

1877

• Kussmaaul proposed a term “word blindness” or caecitas verbalis for an acquired loss of words and introduced visual analogy

1887

• Berlin first used the term “dyslexia” in his monograph referring to acquired loss of reading ability

1892

• Dejerine deduced lesion in medial and inferior portion of left occipital lobe could lead to dyslexia- “brain letter box”

1896• Pringle Morgan was first to note a case of dyslexia

1917

• Hinshelwood defined word blindness as pathological condition caused by disorder of visual centers of brain and caused difficulty in interpreting written language


1937

• Orton (regarded as father of Dyslexia society) observed children with reading problems had near average or above average IQ

1962• The term “learning disability” appeared in print (Kirk)

1977

• US passed a law stating all school must provide special education to the child with LD. IQ discrepancy formula given

1985

• Between 1985 to 2000 several authority gave different definitions for LD

1990…• Advances in the research – neurobiology and genetic


• Earlier understanding of LD was more in terms of medical model

– Explanation in terms of brain damage or brain dysfunction

• Absence of hard evidence lead to development of the educational framework for defining from 1960s

– Emphasis on discrepancy

– Visuo- motor problem

• From 1980s onwards US National Joint Committee on LD formulated the concept involving all the previously concerned discipline

• 1990 onwards more emphasis on the dimensional nature of problem rather than categorical

– Adopted more by researchers (yet to be adopted by practitioners)

2 major factors that have emerged • Life span approach • Language based problem

Pratibha Karanth, 2003



• Epidemiology

• Pathophysiology


• Prognosis


• Conclusion

CONCEPTS

• Disorders interfering with the acquisition and use of one or more of the following academic skills: oral language, reading, written language, mathematics

NJCLD, 1988

• These disorders affect individuals who otherwise demonstrate at least average abilities essential for thinking or reasoning

• Learning Disorders are distinct from Intellectual Developmental Disorders

Larry B. Silver,2001

CONCEPTS

UK

Learning disability includes the presence of:

• Significantly reduced ability to understand new or complex information, to learn new skills (impaired intelligence)

• Reduced ability to cope independently (impaired social functioning)

• Started before adulthood, with a lasting effect on development

Eric emersion 2010

CONCEPTS

• DSM (DSM-III), the issue of problems with learning was first addressed“Academic Skills Disorders” AXIS II

• Motor and language difficulties also addressed under “Motor Skills Disorders” - category for fine motor/handwriting difficulties

• “Communications Disorders” - categories for Receptive Language and for Expressive Language Disorders

• “Specific arithmetical retardation” – ICD 9 and “Developmental arithmetic disorder”- DSM III

• Developmental expressive writing disorder – DSM III

CONCEPTS:ICD Vs DSM

DSM 5 has Specific Learning Disorder as a single overall diagnosis incorporating deficits that impact academic achievement

Criteria describes shortcoming in general academic skillDetailed specifier for reading, mathematics and written expression

Both require evidence of a substantial discrepancy between scores on reading achievement test and measured intelligence

CONCEPTS

Types :

• Dyslexia

• Dyscalculia

• Dysgraphia

Associated deficits and disorders:

• Auditory Processing Deficit

• Visual Processing Deficit

• Non-Verbal Learning Disabilities

• Executive Functioning Deficit

National center for learning disability,2014

APPROACHES

• Difference between aptitude and achievement

• Difference between IQ and achievement test scores

Discrepancy

• Multiple domains

• Reading, mathematics , written expression, language

Heterogeneity• No sensory disorder,

mental deficiency, emotional disturbance

• No economic disadvantage, linguistic diversity or inadequate instructions

exclusion

Individuals with Disabilities Education Act (IDEA),2004

No change in this discrepancy approach since 1977 when first approved by US law

APPROACHES- STATIC MODELS

Ability achievement discrepancy

Difference between intellectual ability and performance

No difference in identification with other model

Low achievement model

Student performing below a certain threshold

Doesn’t facilitate whether the child’s low achievement is proportionate to the ability

No distinguish high ability student with average achievement

Intraindividual discrepancy

model

Uneven profile of cognitive measures

Over identification

Kavale 2001

APPROACHES

CRITICISM

• With a low IQ score it is difficult to show an even lower reading test score: introduces a bias against diagnosing dyslexia in less able children

Miles and Haslum (1986)

• Delay in intervention until student’s achievement is low

• Delayed intervention might result to refractory to intervention

• Even criticized as “wait to fail” model

• Overidentification of students who are disadvantaged, ethnic minority, display oppositional behavior

Fletcher, 2004

APPROACHES

RESPONSIVENESS TO INTERVENTION AS DEFINING MODEL:

• Universal screening of all students for reading difficulties in the early school years

• Placement in early intervention programs

• Students can be identified with LD if they maintain deficient achievement, do not adequately respond to increasingly intense instructions

Fletcher, 2004

APPROACHES

RESPONSE TO INTERVENTION- ADVANTAGES

• Shifting of focus from eligibility to concerns about providing effective instruction

• No waiting for students to meet IQ-discrepancy criteria (wait to fail) to identifying students who need intervention as early as possible and providing it immediately

• Not dependent on teacher referral that could be disproportionate

Douglas Fuchs, 2006



• Epidemiology

• Pathophysiology


• Prognosis


• Conclusion

EPIDEMIOLOGY

National centre of learning disabilities, 2014

EPIDEMIOLOGY

• Lifetime prevalence of specific learning disorders (SLD) in age groupfrom 3 to 17 years of age is 9.7%

– Those with special health care needs (28%)

– Typically developing children (5.4%)

• 2.5 million public school students , 5% of all students in public schools—were identified as having learning disabilities in 2009 in US

National center of learning disabilities, 2014

• Reading disability accounts for 80-90% of all learning disabilities

• Boys> girls

(Lerner et al, 1989; Altarac et al ,2007)

EPIDEMIOLOGY:INDIASTUDY N Urban/ rural Place Tools RESULT

Yadav et al, 2008 N=800 Rural AllahabadSchool

Teachers opinionAchievementrecords

2.25%

Vijayalaxmi , 2009 N=1134 Urban BangaloreSchool

NIMHANS battery

15.17%

Mogasale et al,2011

N=1134 Urban Bangalore,school

NIMHANS battery

15%

Choudhary et al,2012

N=500class 3-5

urban Bikanerschool

Dyslexia Assessment Questionnaire

10.25%

Dhanda and Jagawat, 2013

N=1156 Rural JaipurSchool

IPS questionnaire 12.8%

Arun et al, 2013 N=2402Class 7-12

Urban Chandigarh school

NIMHANS battery

1.58%

Variability may be due to• Rural urban • Teacher screening only • Language differences • Socio economic status • Teacher interview plus performance • Methods of assessment• ?Geographical variation

EPIDEMIOLOGY


CORE PROBLEMS

• Receptive language- difficulty to process speech sounds

• Visual perception defects-misinterpretation of words

INPUT

• Sequencing

• Abstraction

• OrganizationINTEGRATION

• Working: Information fragment into full concept

• Short term: information recall

• Long term: metacognitive skills like studying , inability to recall

MEMORY

• Language problems

• Motor problems OUTPUT

Turnbull et al, 2004

MANIFESTATIONS

READING

• Slow, hesitant word by word reading

• Reading without punctuation

• Mirror reading, word guessing

• Omission substitution, addition of words

• Understanding, recall and drawing inference

WRITING

• Avoiding or slow writing

• Awkward pencil holding

• Poor handwriting, spelling, size inconsistency, mixing small and capital letters

• Transposition, mirror writing, add or omit letters in words

MATHEMATICS

• Longer time

• Mistakes in sums involving 0

• Difficulty in keeping tenth, hundredth or thousand place

• Carry over or borrowing problem

• Difficulty in word problems

ASSOCIATED PROBLEMS

BEHAVOURAL

• Laying blame on teachers

• Making excuses for bad behavior

• Exhibiting “I give up” attitude

• Avoiding confrontation about school

Social

• Poorly accepted by friends

• Greater risk for social alienation from teachers and classmates

• Less social activity

• Impulsive answers

• Inappropriate answers

• Get bullied

Emotional

• Remain aloof

• Feeling low

• Anger and frustration

• Poor self esteem

• Receive a more negative assessment of social skills difficulties• Poor self-esteem, frustration, and other barriers to developing social skills• Lead to behavioral problems

Forness and Kavale,1996

MOTOR INCORDINATIONAmong 137 children with LD , 50.4% of the children performing below the 15th percentile on the Movement assessment Battery(balance coordination, manual dexterity, ball skills etc.)

Vuijk et al, 2011

COMORBIDITIES

? Shared etiologic and neurocognitive risk factors

ADHD

Language Impairment

Speech Sound

Disorder

Learning disability

ADHD, SSD, and LI are all likely to be apparent earlier and can thus indicate a child’srisk for later reading problems

Pennington et al 2009

COMORBIDITIES

• Willcutt et al, 2000

• N=209 twins with reading disability

• n-=192 without RD

• DSM-III Diagnostic Interview for Children and Adolescents, Parent Report Version

• Child self-report version of the Diagnostic Interview for Children and Adolescents

COMORBIDITIES

STUDY SAMPLE TOOLS RESULTS

Margari et al 2013

448 Italian children 7-16 yrs.

• DSM IV TR• Standardizeddiagnostic tests for neuropsychological and psychopathological evaluation

Total Comorbidity % -58.3%ADHD-33%Anxiety disorder-28.8% Mood disorder -9.4% Language disorder 11% Motor coordination disorder 17.8%

Gallegos et al, 2012

120 Mexican children with LD and 120 without LD9 to 12 years old

• LD via school records

• Spence Children’s Anxiety Scale

• Children’s Depression Inventory

Anxiety –23.3% VS 11.5%

Depression-32% VS 18%

COMORBIDITIES

The median LD prevalence rate across the 17 ADHD Studies was 31.1%, Control: median prevalence of 8.9%

The prevalence rate of ADHD in LD a median prevalence of

38.2% across studies

Control: 5%

DuPaul and Stoner (2003) reviewed 17 studies conducted between 1970s to 1990s that reported the percentage of students with

1982- 19931978-1993

• Publications from the past decade (i.e., 2001–2011) were reviewed

• Rates of LD in students with ADHD ranged from 8% to 76% of students (Median = 47%, M = 45.1%)

Dupaul et al 2012



• Epidemiology

• Pathophysiology


• Prognosis


• Conclusion

ETIOPATHOGENESIS-THEORIESTHEORY EXPLAINATION LIMITATIONS

Phonological Specific impairment in the representation, storage, and/or retrieval of the speech sounds

Inability to explain the occurrence of sensory and motor disorders in dyslexic individuals

The rapid auditory processing theory

failure to represent short sounds with fast transition would cause difficulty in response to the acoustic events with phonemic contrast like /ba/ vs /da/

Same

Visual theory Abnormality in the magnocellular layers of lateral geniculate nucleus

Failure to replicate the visual findings

Scerri and Schulte Korne, 2010

ETIOPATHOGENESIS-THEORIES

THEORY EXPLAINATION LIMITATIONS

Cerebellar theory • Motor control, speecharticulation, automatization of repetitive task like driving reading

• Brain imaging studies also show anatomical, metabolic and activation differences

• Outdated view of the motor theory of speech

• Cases of normal phonological development despite severe dysarthria or apraxia of speech

The magnocellular (auditory and visual) theory

Combines both auditory and visual theoriesGeneral impairment in magnocellular pathwaysVisual, auditory and tactile sensory modalities affected

• Each theory can only explain a proportion of individuals with dyslexia

• Possibility that each theory may account for different sub-sets of dyslexia brought about by different etiologies

Scerri and Schulte Korne, 2010

ETIOPATHOGENESIS-THEORIES(3 TIER)

Biological

• Left hemisphere disconnection

cognitive

• Phonological deficit

• Poor Graph-phoneme knowledge

Behavioral

• Poor reading

• Poor phoneme awareness

• Poor STM

• Poor naming speed

ENVIRONMENTAL FACTORSTeaching method Cultural factors Socio economic factors

Frith, 1999


Biological

• Frontal temporal area

Cognitive

• Phonological deficit

• Attention deficit

• Poor inhibitory control

• Poor graph-phoneme

Behavioral

• Poor planning

• Poor achievement

• Poor reading

• Poor naming skill


Frith, 1999


Biological

• Magnocellularabnormality

cognitive

• Slow temporal processing

• Auditory and visual deficit

• Phonological deficiit

Behavioral

• Poor tone

• Poor reading

• Poor coordination

• Poor speech development


Frith, 1999

ETIOPATHOGENESIS(LANGUAGE)

• 30 dyslexic children from urban India(New Delhi ) English medium school

• Hindi and English word reading task

• A significantly greater accuracy for Hindi word reading than English (42% vs 30%)

Language Phonetic Orthographic

Hindi 65% 15%

English 57% 35%

• Reading strategies are affected in part by the orthographic transparency of the language

• Hindi- Shallow(spelling-sound correspondence is direct)• English- Deep(reader must learn the arbitrary or unusual pronunciations of

irregular words.)

Ashum Gupta, 2006

NEUROBIOLOGY

• First reported by Dejerine in 1891 that damage to (angular gyrus) resulted in variable degree of impairments in reading and writing

• Autopsy

– Symmetrical Plannum Temporale - triangular structure on the superior surface of the temporal lobe inside the Sylvian fissure (SF) and it is a region of the cortex that falls within the Wernicke’s area( left hemisphere)

– cortical malformations in the form of neuronal ectopias, architectonic dysplesias (focally distorted cortical architecture) and microgyria (abnormal infoldings)

– Disorganized magnocellular layers of visual pathway and smaller medial geniculate nucleus in left of auditory pathway

SO Wajuihian ,2011

NEUROBIOLOGY

• MRI studies

– Studies divided in the symmetry of PT

– higher degrees of asymmetry of the temporal lobes

– No consistent finding

SO Wajuihian ,2011

NEUROBIOLOGY -FUNCTIONAL

STUDY SAMPLE SIZE

TASK FINDING

Corina et al, 2000 8 case 8 controls

Phonological and lexical auditory judgement

Activation in right than left in left temporal gyrus(phon) Less activity in b/l middle frontal gyrus and more activity in left orbital frontal cortex (lexical)

Shulz et al, 2008 16 case 13 control

Identical sentence reading

Decreased activation of frontal and inferior parietal regions of LH

Richards et al, 2008 18 case 21controls

Phoneme mapping task

Greater functional connectivity between left inferior fronytal gyrus to right


STUDY SAMPLE SIZE

TASK FINDING

Richlan et al, 2010 15 cases 15 controls

Phonological lexicaldecision task

Dysfunction in regions of left occipito-temporal accompanied by absent responsiveness in phonological regions of inferior frontal gyrus

Rimrodt et al, 2009 15 case 15 control

Sentencecompletion to word recognition

areas associated with linguistic processingMore activation


Meta analysis 7 original studies on functional abnormalities in the dyslexicActivation Likelihood Estimation (ALE)

Underactivationinferior parietal, superior temporal, middle and inferior temporal fusiform regions of the left hemisphere

Overactivationinferior frontal gyrus primary motor cortex anterior insula

• Contrary to previous findings of compensatory activation of right hemisphere and posterior region

Richan et al, 2009

Left Inferior frontal gyrus

(Activates during phoneme/word

production/ articulation )

Left Parietal-temporal

(word analysis or phonological

decoding )

Left occipital-temporal

(word form recognition )

Compensatoryincrease

Hypoactivation

No Corresponding Increased activation – RIGHT SIDED Posterior regions as opposed to previous meta analysis

NEUROBIOLOGY ANATOMICAL

• White Matter decreases in the left frontal and parietal portions of the arcuate fasciculus

• Gray matter density decrease in dyslexics in the key area of functional underactivation (left medial temporal gyrus)

• Family study – the grey matter changes present from beforehand/ as a risk factor

• Altered connectivity in specific WM tracts ( left superior longitudinal fasciculus) compromise the acquisition of language and cognitive skills important for reading

Peterson and Pennington, 2012

GENETICS - PATHOPHSYSIOLOGY

The genetic architecture underlying dyslexia is complex and multifactorial

9 susceptibility genes named DYX1 to DYX9 with various candidate genes

No genome wide association studies till date

Two or more genes contribute to the phenotype

Polygenecity

Same disorder can be caused by multiple origins in different individual

Heterogeneity

Scerri et al, 2010

GENETICS - PATHOPHYSIOLOGY

• Studies of post-mortem dyslexic brains

– cerebrocortical neuronal migration disorders ranging from small heterotopia to focal microgyria

• All the Dyslexia candidate genes play a central role to a signaling network involved in neuronal migration and neurite outgrowth

abnormal neuronal migration

anomalous brain

oscillations

Auditory signal

disturbance

Poor phonological processing

Scerri et al, 2010

ETIOLOGY

• Literary outcomes

• Reward and punishment

• provision of teaching,

• cultural attitudes

• socio-economic

factors

• Underlying Process

• Genetic

• Neuro-Anatomical

Biological Cognitive

BehavioralEnvironm

ental

The overall etiology can be summarized as the interplay of different factors



• Epidemiology

• Pathophysiology


• Prognosis


• Conclusion

ASSESSMENTAUTHORS NAME CONTENT AREAS REMARKS

Kapur, John, Rozario and Oommen, 1991

NIMHNSIndex for SLD

Level1-preacademic skills 5-7 yrsof ageLevel 2- class1-7

Conjunction with MISICAreas: Attention, reading, spelling, perceptuo-motor, visuo-motorMemory, arithmetic

Validity and reliability definesEnglish and HindiCut off provided

Konanthambigiand shetty, 2008

Scale Developed at special education cell of SNDT women university

Using behavior checklist For teachers for identification

Validity not defined

Yadav and Agrawal, 2008

Learning disability scale

19 questions in 5 areas

Verbal disability, oral attention disability, writing disability, mathematical computation disability, written attention disability

Short scaleEasy administration Validity not known

ASSESSMENTSTUDY BATTERY CONTENT REMARKS

Mehta M and Sagar R, 2003

AIIMS SLD battery

Bender Visuo-Motor Gestalt test

for motor co-ordination

Reading (using NCERT book

text)

Expression - verbal and written

Comprehension

Arithmetic

Non verbal SLD

No cut offQualitativescale

Apart from these Indian scales there are other questionnaire • Diagnostic reading scales• Reading Acquisition Profile in Kannada (RAP-K) in Kannada (Prema1998)• Behavioral checklist for screening the learning disabled (Swarup and

Mehta ,1991)• Wechsler Objective dimension(1993)• Woodcock Johnson 3 achievement(2001)• Wide Range achievement test • Schonell spelling test

ASSESSMENT

Step 1: Gather the history

Step2: Standardized assessment

Step 3: Behavioral Observation during assessment

ASSESSMENT

Step 1: Gather the history



• Developmental • Educational• Emotional and behavioral• Classroom observation of learning behavior

• Attention• Organization • Homework• Test taking behavior

• Social interaction with peers

ASSESSMENT



• Cognitive ability• Malin's Intelligence scale for Indian children• Wechsler Intelligence Scale for children IV• Stanford Binet

• Information processing• Auditory and visual• Memory and executive functioning

• Achievement• Reading• Writing• Mathematics

ASSESSMENT


• Level of anxiety• Fatigue• Handwriting, pencil grip, pressure while writing• Ability to sustain attention during assessment

Integrated approach involving audiologist, ophthalmologist, neurologist, speech therapist, occupational therapist, pediatrician and psychiatrist

SN PROFESSIONAL ROLE ASSESSMENT

1 The Pediatric Neurologist

detailed clinical history and thorough physical examination• exclude medical cause• identify behavioral causes

2 Counsellor • Rule out any environmental deprivation due to poor home or school environment, or any emotional problem due to stress at home or at school

3 Clinical Psychologist

• Conduct the standard intelligence test to determine IQ and rule out intellectual disability

• Assess the learning disability in different areas using Battery of tests

• Assess: Emotion and Behavioral problems the child is facing Comorbidities, Other Psychological issues

• Assess: Neuropsychological deficits

4 The Special Educator

• Further assess and address the issues accordingly

5 Child Psychiatrist

• Rule out diagnosis of other conditions which cause poor school performance, viz., "isolated" ADHD, depression, conduct disorder, and oppositional defiant disorder

MANAGEMENT

SN PROFESSIONALS MANAGEMENT

1 Clinical Psychologists • Psychoeducation• Provide psychotherapy for the

emotional problems, anxiety, behavioral problems, poor self esteem

• Address the neuropsychological problems

2 Psychiatrists • Provide psychotherapy • Medications if required for the

comorbidities

3 Special educators • Major role in providing training and special education as per need of the child

INTERVENTION

Fox et al, 2009

INTERVENTIONS(READING)

• High interest/low vocabulary materials

• Multisensory method

• Programmed reading, Remedial reading drills, Neurological Impress method

Fernald method(whole word approach): 4 steps

• select a word in flash card, trace with fingers, say it loud

• Repeat without tracing

• Repeat without writing

• Learn new word from the last word

Gillingham method(Phonic method):

• One letter in card spoken by teacher

• Repeated by student many times

• Expose card and ask

• Teacher makes sound represented by letter and ask the letter

INTERVENTIONS(WRITING)

• Handwriting practice

• Fading model

– Match upper and lower case

– Make association like p=Flag

• Cover and write method

• Spelling games: blocks, scrabbles

• Multisensory like in reading creating distinct visual image and habit formation through repetition

• Showing student his wrong spelling and correcting it in front

INTERVENTIONS(MATHEMATICS)

• Number work exercises

– Classification: grouping of objects according to their distinguishing character

– Ordering and sequencing on the basis of properties

– One to one correspondence: distributing pencils, matching school bags

• Multiplication addition etc with beads, blocks or straws

• Weave math into daily life



• Epidemiology

• Pathophysiology


• Prognosis


• Conclusion

PROGNOSIS


PROBLEMS IN ADULT

• Systemic review

• 33 studies 318 factors extracted and classified in International Classification of functioning disability and health (ICF)

• Adult dyslexic came out with the problems in the domains as :

– Negative feelings and emotions like frustration insecurity, anger, stigmatized, inferiority feeling

– Difficulty in organizing and planning

– Difficulty solving problems

– Difficulty in reading or writing

– Difficulty acquiring and keeping job

– Poor support and negative attitude at work- Fear of demotion

All the domains of life personal , environment , social affected by dyslexia Beer et al, 2014



• Epidemiology

• Pathophysiology


• Prognosis


• Conclusion

ISSUES INDIAN CONTEXT

Certification of SLD

• No uniform national guidelines for diagnosis and assessment of severity and certification of SLD

Difficulties in creating uniform assessment tools:

• Multiple language spoken in India

• Awareness problems in parents and teacher

• differences in quality of teaching , school environment, student teacher rat

Facilities

• Not recognized as a disability in the PWD Act 1995

• Provision like extra time , change in the subject etc. by CBSE board

• No consensus among the boards

25 item questionnaire regarding knowledge of LD in regular school, pre service and special school teachers • Minimum knowledge in pre

service teacher• 70% supported LD as a

problem.(Saravanabhavan , 2010)

50 parents of LD(semi structured questionnaire)Only 16% aware of cause, 66% felt some kind of education needed and only 11% knew it was a life long disorder(Karangde, 2007)

Abuse of certificates in urban areas • Ambitious parents

• Demand certificates even if children are dull average in intelligence

• Instances where children asked to make deliberate mistakes

• School authorities • Concerned about

results by giving facility of provisions

• Untrained professionals• Training as a business

Mehta, M, 2011

Right of Children to Free and Compulsory

Education Act, 2009 (RTE Act)

Pros

• Makes education for children 6-14 yrs. of age free and compulsory

• No child held back, expelled or required to pass a board examination until completion of class standard VIII

• Preventing the stress, maladjustment or behavioral problems related to detention

Cons

• Late referral of the children to learning Disability clinic

• LD children would be diagnosed late

• Crucial time period for "remedial education" i.e. lost opportunity to overcome Disability will be lost

• Psychological trauma to the child and to the parents

Unni,2012

Right of Children to Free and Compulsory

Education Act, 2009 (RTE Act)

Pros

• Makes education for children 6-14 yr of age free and compulsory

• No child held back, expelled or required to pass a board examination until completion of class standard VIII

• Preventing the stress, maladjustment or behavioral problems related to detention

Cons

• Late referral of the children to learning Disability clinic

• Dyslexic children would be diagnosed late

• crucial time period for "remedial education" will be lost i.e. lost opportunity to overcome Disability

• Psychological trauma to the child and to the parents

Amendment that mandates that children who are getting poor marks/grades, irrespective of their class standard, are referred to a Learning Disability clinic to undergo an assessment of their academic difficulties

Unni,2012

PATHWAYS TO CARE

• N=50 cases of specific learning disability

• 8-16 yrs

• Pathways to Care Instrument devised by Goldberg and Huxley

Mean time 1st care 1.08 yrs

Mean time tertiary care 3.39 yrs

PresentationcomorbidityPoor academics

14%64%

Chakraborty et al, 2014

TIME LAG IN DIAGNOSIS

• 50 children diagnosed with SLD and/or ADHD

• Hospital based

• Average age of diagnosis: 11.36

• Average age at which children’s symptoms noticed: 5.55yrs

• Delay: 6 yrs.

• 30% already had class retention

• 40% had aggressive or withdrawn behavior

• Significant lag in detection and diagnosis• Children with SLD and co-occurring ADHD need to be

identified at an early age to prevent poor school performance and behavioral problems

Karande et al , 2007

FACTORS FOR IDENTIFICATION

• Educational longitudinal study

• N=16000 from 750 schools

Positive predictors of identification

• Language minorities i.e. foreign language as first language

• The students enrolled in ELS

• Male

• Non white population

Negative predictors of identification

• Student enrolled in US schools after primary education

Shifrer et al, 2010

FACTORS FOR RECOGNITION

Difficulties in India

• Multi language and multicultural setting

• 18 different orthographic forms of language

• 3 language system in education State, Hindi and English

• Lack of tools of assessment in different language

S Rama, 2000



• Epidemiology

• Pathophysiology


• Prognosis


• Conclusion

CONCLUSION AND WAY FOREWARD• There has been a progressive shift in the understanding of learning

disability as a disorder and last decade has seen good number of research in this field

• There have been criticism in the definitional issues from past that continue to happen in present

• Children with learning disability face problems in multiple facets of life (with or without comorbidities) even when they become adult –early intervention warranted

• Despite a lot of research the it hasn’t been possible to formulate causal mechanism – role of neurobiology and genetics present but exact mechanism not known

CONCLUSION AND WAY FOREWARD

• In Indian prospective research are limited even to determine the overall prevalence

• Lack of tools in different language and lack of grading system has made assessment difficult

• Legislative support for the dyslexic children throughout the country via proper policy and facilities is warranted

• Further research in this field warranted

learning disorder/dyslexia/specific learning disorders

Health & Medicine

evolution of concept

reasoning learning disorders

language difficulties

academic skills disorders

written language

receptive language

oral language

important issue