Medical Aspects of Specific Learning Disabilities (SpLD)

Sunil KarandeSunil Karande

Associate Professor of PediatricsAssociate Professor of Pediatrics

Learning Disability ClinicLearning Disability Clinic

Department of PediatricsDepartment of Pediatrics

LTM Medical College & General HospitalLTM Medical College & General Hospital

MumbaiMumbai

Specific Learning Disabilities Specific Learning Disabilities (SpLD)(SpLD)

Group of developmental disordersGroup of developmental disorders Significant unexpected, specific and persistent Significant unexpected, specific and persistent

difficulties in the acquisition and use of difficulties in the acquisition and use of reading (reading (dyslexiadyslexia), writing (), writing (dysgraphiadysgraphia) or ) or mathematical (mathematical (dyscalculiadyscalculia) abilities, ) abilities,

despitedespite conventional instruction, normal conventional instruction, normal intelligence, proper motivation and adequate intelligence, proper motivation and adequate socio-cultural opportunity socio-cultural opportunity

The child with SpLD is one who does not meet The child with SpLD is one who does not meet expectations for academic performance in school expectations for academic performance in school but has intelligence in the normal rangebut has intelligence in the normal range

““a severe discrepancy between achievement and a severe discrepancy between achievement and intellectual ability in one or more of the following intellectual ability in one or more of the following areas: areas: Oral expression Oral expression Listening comprehensionListening comprehension Written expressionWritten expression Basic reading skillBasic reading skill Reading comprehensionReading comprehension Mathematical calculationsMathematical calculations Mathematical reasoning”Mathematical reasoning”

What is not SpLD !!!!What is not SpLD !!!! ““Slow learners” (IQ 71 to 84)Slow learners” (IQ 71 to 84) Mental retardation (IQ ≤ 70)Mental retardation (IQ ≤ 70) Visual handicap (>60% disability)Visual handicap (>60% disability) Hearing handicap (> 60% disability)Hearing handicap (> 60% disability) Physical handicap (e.g. cerebral palsy)Physical handicap (e.g. cerebral palsy) Language barrierLanguage barrier Emotional problems / Chronic medical Emotional problems / Chronic medical

problemsproblems Psychiatric disorders (e.g. depression)Psychiatric disorders (e.g. depression)

Brief History of SpLDBrief History of SpLD

1878: Dr. Kussmaul (Germany) described a 1878: Dr. Kussmaul (Germany) described a man with normal intelligence but unable to man with normal intelligence but unable to read in spite of an 'adequate' education. He read in spite of an 'adequate' education. He called this condition “reading blindness”called this condition “reading blindness”

1896: Dr. Pringle Morton (UK) described 14- 1896: Dr. Pringle Morton (UK) described 14- year-old boy with reading difficulty: year-old boy with reading difficulty:

The teacher:- “he would be the smartest lad in The teacher:- “he would be the smartest lad in the school the school ifif instruction were entirely oral” instruction were entirely oral”

1925: Dr Samuel Orton (USA) proposed the 1925: Dr Samuel Orton (USA) proposed the theory of “specific learning difficulty”theory of “specific learning difficulty”

1936: Anna Gillingham and Bessie Stillman 1936: Anna Gillingham and Bessie Stillman published "Remedial Training for Children with published "Remedial Training for Children with Specific Disability in Reading, Spelling and Specific Disability in Reading, Spelling and Penmanship"Penmanship"

1963: Dr. Samuel Kirk (USA) first used term 1963: Dr. Samuel Kirk (USA) first used term “ “learning disabilities”learning disabilities”

1969: “The Children with Specific Learning 1969: “The Children with Specific Learning Disabilities Act (USA)” passedDisabilities Act (USA)” passed

1977: Public law fine tuned ensuring rights 1977: Public law fine tuned ensuring rights of American children with SpLD to of American children with SpLD to 'appropriate evaluation' and 'management' of 'appropriate evaluation' and 'management' of their problemtheir problem

“ “every SpLD child will participate in same every SpLD child will participate in same curriculum and have same academic curriculum and have same academic objectives” objectives”

History of SpLD in IndiaHistory of SpLD in India

1987: SNDT College starts B.Ed. (Special 1987: SNDT College starts B.Ed. (Special Education) course: Special Educators for Education) course: Special Educators for remediation availableremediation available

1992: Parent group start “lobbying” for 1992: Parent group start “lobbying” for recognition of SpLD so that these children recognition of SpLD so that these children continue education in regular schoolscontinue education in regular schools

1995: Maharashtra Dyslexia Association 1995: Maharashtra Dyslexia Association formed by parents of SpLD children formed by parents of SpLD children

1996: L.D. clinic at LTMG (Sion) Hospital

started by Prof. Madhuri Kulkarni 1996: Govt. of Maharashtra issues G.R.

which grants provisions for first time in India;

but for standards IX and X only 1999: ICSE and CBSE boards also grant

provisions

2000: Provisions extended from standard I to XII

2003: Provisions extended to college courses; Seats “reserved” for SpLD in physically handicapped category in colleges, including professional courses

Facts about SpLDFacts about SpLD

5-15% school population5-15% school population Intrinsic to the individualIntrinsic to the individual Invisible HandicapInvisible Handicap ? Genetic in origin? Genetic in origin Due to CNS dysfunctionDue to CNS dysfunction Chronic life-long conditions Chronic life-long conditions

Genetics Of DyslexiaGenetics Of Dyslexia

In 1950, Hallgren suggested that dyslexia was In 1950, Hallgren suggested that dyslexia was an autosomal dominant disorderan autosomal dominant disorder

Recent findings:Recent findings: Dyslexia is a genetically heterogeneous and Dyslexia is a genetically heterogeneous and

complex trait that does not show classical complex trait that does not show classical mendelian inheritancemendelian inheritance

Several chromosomal regions have been Several chromosomal regions have been reported to contain genes affecting reading reported to contain genes affecting reading disability (chromosome 1, 2, 3, 6, 15, 18)disability (chromosome 1, 2, 3, 6, 15, 18)

Genetic Disorders Associated Genetic Disorders Associated with SpLDwith SpLD

Sex chromosome anomalies:Sex chromosome anomalies: XXY, XYY, fragile X syndrome, XO XXY, XYY, fragile X syndrome, XO

(Turner’s)(Turner’s) Syndrome NF1 and other neurocutaneous Syndrome NF1 and other neurocutaneous

disordersdisorders PKUPKU

Perinatal Risk FactorsPerinatal Risk Factors

Low birth weightLow birth weight Obstetrical complications:Obstetrical complications: Birth asphyxiaBirth asphyxia Intraventricular hemorrhageIntraventricular hemorrhage

What happens in dyslexia?What happens in dyslexia?

Deficits in “phonologic awareness”Deficits in “phonologic awareness” Phoneme: smallest discernible segment of speechPhoneme: smallest discernible segment of speech "bat" consists of three phonemes: "bat" consists of three phonemes:

/b/ /ae/ /t/ (buh, aah, tuh)/b/ /ae/ /t/ (buh, aah, tuh) Poor awareness that words, both written and spoken, Poor awareness that words, both written and spoken,

can be broken down into smaller units of sound can be broken down into smaller units of sound

and; letters constituting printed word represent and; letters constituting printed word represent sounds heard in spoken wordsounds heard in spoken word

How does SpLD present?How does SpLD present?

Failure to achieve school grades Failure to achieve school grades commensurate with intelligencecommensurate with intelligence

Repeated spelling mistakes, untidy / illegible Repeated spelling mistakes, untidy / illegible handwriting, poor sequencing, inability to handwriting, poor sequencing, inability to perform simple mathematical calculationsperform simple mathematical calculations

School failure / under-achievementSchool failure / under-achievement Adverse impact on self-image, relationshipsAdverse impact on self-image, relationships If undetected: school drop-outs and even anti-If undetected: school drop-outs and even anti-

social elementssocial elements

EEG studiesEEG studies

EEG abnormalities in 50% but no specific EEG abnormalities in 50% but no specific patternpattern

Above minor changes no longer considered Above minor changes no longer considered valid or of any valuevalid or of any value

No role in the evaluation of LDNo role in the evaluation of LD

NeuroimagingNeuroimaging

Absence of usual asymmetry of planum Absence of usual asymmetry of planum temporale (portion of temporal lobe lying temporale (portion of temporal lobe lying posterior to Heschl’s gyrus)posterior to Heschl’s gyrus)

Left is usually larger than rightLeft is usually larger than right Perhaps right being larger than normal is due Perhaps right being larger than normal is due

to failure of neuronal pruningto failure of neuronal pruning

Not certain if brain changes localized to Not certain if brain changes localized to specific areas, or if interaction between specific areas, or if interaction between different areas important in causing SpLDdifferent areas important in causing SpLD

CT / MRI scans not usefulCT / MRI scans not useful

New research tools: fMRI, PET / SPECT New research tools: fMRI, PET / SPECT scansscans

Functional Imaging in Functional Imaging in DyslexiaDyslexia

13 studies: no consistent pattern of hypo- or 13 studies: no consistent pattern of hypo- or hyper activationhyper activation

Abnormalities found in multiple areas, Abnormalities found in multiple areas, sometimes both hemispheressometimes both hemispheres

Most common: hypo activation in left Most common: hypo activation in left temporal lobe during reading taskstemporal lobe during reading tasks

Some studies: activation increased after Some studies: activation increased after remedial therapy for dyslexiaremedial therapy for dyslexia

Attention deficit hyperactivity Attention deficit hyperactivity disorder (ADHD)disorder (ADHD)

Affects 8-12% of childrenAffects 8-12% of children 3 sub-types:3 sub-types: ADHD-I: inattentionADHD-I: inattention ADHD-HI: impulsivity and hyperactivityADHD-HI: impulsivity and hyperactivity ADHD-C: have both ADHD-C: have both At risk for poor school performanceAt risk for poor school performance 20-25% ADHD children have SpLD and vice 20-25% ADHD children have SpLD and vice

versa versa

Evaluation ProcedureEvaluation Procedure Letter from School PrincipalLetter from School Principal

Multi-disciplinary approach:Multi-disciplinary approach:

Medical / Neurological examinationMedical / Neurological examination Vision, Hearing testsVision, Hearing tests Analysis of school reportsAnalysis of school reports IQ testing (WISC test)IQ testing (WISC test) Educational assessmentEducational assessment Psychiatric assessment, if requiredPsychiatric assessment, if required Case conference / Final diagnosisCase conference / Final diagnosis Counseling before Certificate issuedCounseling before Certificate issued

Takes 2-3 wks to completeTakes 2-3 wks to complete

Data from LTMGH LD clinicData from LTMGH LD clinicYearYear Total Total SpLDSpLD SLSL MRMR

19971997 159159 6969 1818 88

19981998 296296 200200 6565 88

19991999 358358 174174 6969 1414

20002000 522522 226226 105105 3333

20012001 475475 171171 8686 2424

20022002 479479 216216 4343 1818

20032003 896896 540540 142142 4747

20042004 966966 699699 9898 1818

20052005 976976 624624 6464 1515

At time of diagnosis:At time of diagnosis:

Each child’s parents counseled:Each child’s parents counseled: SpLD: its meaning, treatment, prognosisSpLD: its meaning, treatment, prognosis Importance of remedial educationImportance of remedial education Provisions at school examinations and at board Provisions at school examinations and at board

examinations in futureexaminations in future Child and parents to choose whether to avail all Child and parents to choose whether to avail all

available provisions or only some of themavailable provisions or only some of them Choice to be made in consultation with school Choice to be made in consultation with school

teachers / remedial teacherteachers / remedial teacher About ADHD if co-morbidityAbout ADHD if co-morbidity

Remedial EducationRemedial Education

Cornerstone of treatment of SpLD Cornerstone of treatment of SpLD Should ideally begin early, when child in Should ideally begin early, when child in

primary schoolprimary school Special Educator formulates Individual Special Educator formulates Individual

Education Program (IEP) Education Program (IEP) Hourly sessions twice / thrice wkly for few yrsHourly sessions twice / thrice wkly for few yrs

Expensive (Rs. 150-800/ session)Expensive (Rs. 150-800/ session) Most schools do not employ special Most schools do not employ special

educators as staff memberseducators as staff members Children have to necessarily take remedial Children have to necessarily take remedial

education from “private” special educators education from “private” special educators Parents not adequately knowledgeable Parents not adequately knowledgeable

about remedial education about remedial education

Role of ProvisionsRole of Provisions SpLD distorts scores causing them to be too lowSpLD distorts scores causing them to be too low

Provisions formulated to help SpLD children Provisions formulated to help SpLD children continue in regular mainstream schoolcontinue in regular mainstream school

Provisions function as ‘corrective lens’: distorted Provisions function as ‘corrective lens’: distorted array of observed scores back to where they ought to array of observed scores back to where they ought to bebe

Provisions serve to "level the play field“: academic Provisions serve to "level the play field“: academic performance now commensurate with intellectual performance now commensurate with intellectual ability ability

Provisions Provisions at SSC board at SSC board examinationexamination Extra time of 30 mins for written tests, spelling mistakes overlookedExtra time of 30 mins for written tests, spelling mistakes overlooked Employing writer for children with dysgraphiaEmploying writer for children with dysgraphia Exemption of 2Exemption of 2ndnd language, substituting with work experience subject language, substituting with work experience subject Exemption of standard X mathematics (algebra and geometry), substituting Exemption of standard X mathematics (algebra and geometry), substituting

with standard VII mathematics and work experience subject with standard VII mathematics and work experience subject

Choice is to be made from a range of 39 work experience subjectsChoice is to be made from a range of 39 work experience subjects [e.g. Typewriting (English), Introduction to Computer, Book Binding,[e.g. Typewriting (English), Introduction to Computer, Book Binding, Hand Embroidery, Drawing & Painting] Hand Embroidery, Drawing & Painting]

Impact of ProvisionsImpact of Provisions

60 children at SSC examn with provisions compared 60 children at SSC examn with provisions compared with performance at last annual school examn before with performance at last annual school examn before diagnosis of SpLD diagnosis of SpLD

Improvement in mean % total marks (63.48 ± 7.86 Improvement in mean % total marks (63.48 ± 7.86 vs.vs. 40.95 ± 7.23 ) 40.95 ± 7.23 )

[mean % difference = 22.53, [mean % difference = 22.53, PP < 0.0001] < 0.0001] Children who availed exemption of 2Children who availed exemption of 2ndnd language or language or

opted for lower grade mathematics scored better opted for lower grade mathematics scored better marks marks

((PP < 0.0001 and < 0.0001 and PP = 0.0009, respectively) = 0.0009, respectively)

Experiences with ParentsExperiences with Parents

Just do not accept diagnosisJust do not accept diagnosis Do not begin remedial educationDo not begin remedial education Instead private tuitionsInstead private tuitions Omit remedial education earlyOmit remedial education early Refuse provisions as it restricts future career Refuse provisions as it restricts future career

options (e.g., child who has opted for lower options (e.g., child who has opted for lower grade of mathematics cannot later have career grade of mathematics cannot later have career in engineering)in engineering)

Experiences with SchoolsExperiences with Schools

Regular Awareness Workshops conductedRegular Awareness Workshops conducted School Principals targeted firstSchool Principals targeted first School Teachers sensitized to suspect SpLDSchool Teachers sensitized to suspect SpLD Initially, many schools uncooperativeInitially, many schools uncooperative Implementation of Govt. rules mandatoryImplementation of Govt. rules mandatory Cannot detain child if provisions not givenCannot detain child if provisions not given

Wish ListWish List

Better awareness amongst parents, school authorities, Better awareness amongst parents, school authorities, doctorsdoctors

Remediation Center in every schoolRemediation Center in every school Standardized psychological and educational tests in Standardized psychological and educational tests in

all languagesall languages Provisions made available to all SpLD children Provisions made available to all SpLD children Tests to identify children “at risk for SpLD” earlyTests to identify children “at risk for SpLD” early Identification of genetic markers for risk of SpLDIdentification of genetic markers for risk of SpLD Neuroimaging studies (fMRI and PET) to unravel Neuroimaging studies (fMRI and PET) to unravel

etiology etiology

THANK YOUTHANK YOU