Overview of Specific Learning Disability Dr. Madhuri Kulkarni Senior Consultant Pediatrician Mumbai Port Trust Hospital Wadala Mumbai Former Prof. of Pediatrics & Dean In-charge LTMGH & LTMMC, Mumbai

Learning Disability Common neuro-developmental disorder Prevalence 5% to 15 % Equal male : female distribution Persistent throughout life Most likely to be familial

Contd..... Across all socio economic classes Problems in learning to read, write, spell or do mathematics and in social behaviour Presumed to be due to CNS dysfunction.

History of LD 1877 : Kussmaul – Word blindness 1896 : Hinshelwood – Dyslexia 1925 : Orton – Special training for dyslexics 1962 : Kirk – Learning disorder / disability 1988 : N.J.C.L.D. 1995 : L.D. Clinic at L.T.M.G.H. 1996 : M.D.A 1996 : State Govt.of Maharashtra

NJCLD Definition Heterogeneous group of disorders manifested by significant difficulties in the acquisition and use of reading, writing, listening, speaking, reasoning and mathematical abilities. These disorders are intrinsic to the individuals, presumed to be due to CNS dysfunction, and may occur across the life span.

Specific Learning Disability Generic term that refers to a heterogeneous group of disorders manifested by significant unexpected, specific and persistent difficulties in the acquisition and use of reading (dyslexia), writing (dysgraphia) or mathematical (dyscalculia) abilities despite conventional instruction, normal intelligence, proper motivation and adequate socio-cultural opportunity. *Shapiro BK-1993

What is not L.D.? Mental Retardation Borderline I.Q. Sensory deficits: Vision, Hearing Emotional disturbances Attention deficits Late maturation

Etiology Genetic - Sibling recurrence rate 40 % - Parent rate 25 – 50 % Chromosomes – Loci on 6 & 15 - Sex chromosome anomalies influencing cognitive functioning Neurofibromatosis, PKU, Tourrett Fragile X etc.

Specific Areas in the Brain

Characteristics Academic problems Dyslexia Dysgraphia Dyscalculia Social interaction deficits Emotional problems

Dyslexia Reading difficulties Dys = difficulty Lexia = words/vocabulary Reading difficulties • Reads slowly and hesitantly • Follows the word with fingers • Mispronounces words • Looses place in text

Contd…… Confusion of letters – ‘bog’ for ‘dog’, inverts ‘n’ for ‘u’ Guessing word from first letter reads ‘farm’ for ‘front’ Skips or adds words when reading aloud Oral work better than written answers

Dysgraphia Difficulty related to writing Writing very small or large, may be impossible to read Faulty pressure used Wrong order, ‘tiem’ for ‘time’ Poor at copying from board Written sentences are jumbled Faulty spacing

Dyscalculia Difficulty in mathematics calculations, tables, logic Counting numbers Mental sums difficult Mixes up symbols ‘+’, ‘-’, ‘=‘ Difficulties in word-problems, understanding mathematical operation Drawing geometric figures

Social skill deficits Poor social comprehension Inability to take the perspective of others Misinterpretation of body language Being easily led Inattentive Impulsive Over-aggressive

Presenting Features Pre-school - Delayed speech - Difficulties in pronouncing/blending letters - Rhyming difficulties - Delay in development of fine motor skills - Trouble learning the alphabet, numbers, days of the week, colours, shapes

Presenting Features - Reading single word Primary school - Spelling errors - May confuse small words: at,to,it, said ,and - May have trouble learning to tell time. - Awkward pencil grip - May have poor fine motor co- ordination

Presenting Features Middle school Reversing sequences Spelling difficulty Laborious reading Comprehension problems Problems on the playground Has trouble with word problems in mathematics

Associated Conditions Attention deficit hyperactivity disorder (ADHD) Obsessive Compulsive Disorder Anxiety disorders Tic disorders and Tourette’s Syndrome Conduct disorders, Oppositional Defiant Disorder Depression

ADHD Attention Deficit Hyperactivity Disorder: genetic, neuro bio-chemical & developmental disorder Characterized by hyperactivity, impulsiveness and short attention 20% of LD children are associated with ADHD

Assessment Multi-disciplinary Approach School referral Medical / Neurological / Development Examination Educational History Vision, Hearing tests Analysis of school reports General cognitive functions Educational assessments Psychiatric assessments Case conference Final diagnosis

Why early diagnosis ? Early acceptance Early intervention Reduction in emotional problems Effective main-streaming Optimum development

Brain plasticity in childhood Sparse Profuse Pruned connections connections connections

Ideal Procedure Referral Stage a) Pre-referral screening b) School committee review Assessment Stage a) Multidisciplinary evaluation b) Case conference, team meeting c) Writing of IEP Intervention Stage a) Implementation of IEP b) Monitoring student progress

What is Remedial Education? A specific method of instruction/teaching Based on specific deficits in performance of child Starts after collecting relevant information about the child’s performance Develops on the strengths Fills in the gaps in learning Enables child to achieve academic skills

Important Points about Remedial Education One-to-one basis in a child friendly environment. Minimum one hour duration. Two to three sessions per week R.E. should continue all the year round and not only during vacations or schooldays. However, the sessions could be intensified during the vacation.

Cont…. Should be started as early as six to eight years of age. R.E. is not equivalent to giving tuitions but done by special educators or by the teachers specially trained in remedial education. R.E. has to be given in addition to regular school work. R.E. should be continued throughout school life.

Key message L.D.commonly present as school problems Early detection :Early intervention Clinical features vary with age & with achievement of developmental skills Multi-disciplinary approach Remedial Education Provisions Parent Support and school support MVK NAGPUR 2009

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