Medical Aspects of Specific Learning Disabilities (SpLD) Sunil Karande Associate Professor of Pediatrics Learning Disability Clinic Department of Pediatrics LTM Medical College & General Hospital Mumbai

Specific Learning Disabilities (SpLD) Group of developmental disorders Group of developmental disorders Significant unexpected, specific and persistent difficulties in the acquisition and use of reading (dyslexia), writing (dysgraphia) or mathematical (dyscalculia) abilities, 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 despite conventional instruction, normal intelligence, proper motivation and adequate socio-cultural opportunity

The child with SpLD is one who does not meet expectations for academic performance in school but has intelligence in the normal range The child with SpLD is one who does not meet expectations for academic performance in school but has intelligence in the normal range “a severe discrepancy between achievement and intellectual ability in one or more of the following areas: “a severe discrepancy between achievement and intellectual ability in one or more of the following areas:  Oral expression  Listening comprehension  Written expression  Basic reading skill  Reading comprehension  Mathematical calculations  Mathematical reasoning”

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

Brief History of SpLD 1878: Dr. Kussmaul (Germany) described a man with normal intelligence but unable to read in spite of an 'adequate' education. He called this condition “reading blindness” 1878: Dr. Kussmaul (Germany) described a man with normal intelligence but unable to read in spite of an 'adequate' education. He called this condition “reading blindness” 1896: Dr. Pringle Morton (UK) described 14- year-old boy with reading difficulty: 1896: Dr. Pringle Morton (UK) described 14- year-old boy with reading difficulty: The teacher:- “he would be the smartest lad in the school if instruction were entirely oral” The teacher:- “he would be the smartest lad in the school if 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)” passed Disabilities 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 problem their 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 India 1987: SNDT College starts B.Ed. (Special Education) course: Special Educators for remediation available 1987: SNDT College starts B.Ed. (Special Education) course: Special Educators for remediation available 1992: Parent group start “lobbying” for recognition of SpLD so that these children continue education in regular schools 1992: Parent group start “lobbying” for recognition of SpLD so that these children continue education in regular schools 1995: Maharashtra Dyslexia Association formed by parents of SpLD children 1995: Maharashtra Dyslexia Association 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 SpLD 5-15% school population 5-15% school population Intrinsic to the individual Intrinsic to the individual Invisible Handicap Invisible Handicap ? Genetic in origin ? Genetic in origin Due to CNS dysfunction Due to CNS dysfunction Chronic life-long conditions Chronic life-long conditions

Genetics Of Dyslexia In 1950, Hallgren suggested that dyslexia was an autosomal dominant disorder In 1950, Hallgren suggested that dyslexia was an autosomal dominant disorder Recent findings: Recent findings:  Dyslexia is a genetically heterogeneous and complex trait that does not show classical mendelian inheritance  Several chromosomal regions have been reported to contain genes affecting reading disability (chromosome 1, 2, 3, 6, 15, 18)

Genetic Disorders Associated with SpLD Sex chromosome anomalies: Sex chromosome anomalies:  XXY, XYY, fragile X syndrome, XO (Turner’s) Syndrome NF1 and other neurocutaneous disorders Syndrome NF1 and other neurocutaneous disorders PKU PKU

Perinatal Risk Factors Low birth weight Low birth weight Obstetrical complications: Obstetrical complications:  Birth asphyxia  Intraventricular hemorrhage

What happens in dyslexia? Deficits in “phonologic awareness” Deficits in “phonologic awareness” Phoneme: smallest discernible segment of speech Phoneme: 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, can be broken down into smaller units of sound Poor awareness that words, both written and spoken, can be broken down into smaller units of sound and; letters constituting printed word represent sounds heard in spoken word and; letters constituting printed word represent sounds heard in spoken word

How does SpLD present? Failure to achieve school grades commensurate with intelligence Failure to achieve school grades commensurate with intelligence Repeated spelling mistakes, untidy / illegible handwriting, poor sequencing, inability to perform simple mathematical calculations Repeated spelling mistakes, untidy / illegible handwriting, poor sequencing, inability to perform simple mathematical calculations School failure / under-achievement School failure / under-achievement Adverse impact on self-image, relationships Adverse impact on self-image, relationships If undetected: school drop-outs and even anti- social elements If undetected: school drop-outs and even anti- social elements

EEG studies EEG abnormalities in 50% but no specific pattern EEG abnormalities in 50% but no specific pattern Above minor changes no longer considered valid or of any value Above minor changes no longer considered valid or of any value No role in the evaluation of LD No role in the evaluation of LD

Neuroimaging Absence of usual asymmetry of planum temporale (portion of temporal lobe lying posterior to Heschl’s gyrus) Absence of usual asymmetry of planum temporale (portion of temporal lobe lying posterior to Heschl’s gyrus)  Left is usually larger than right  Perhaps right being larger than normal is due to failure of neuronal pruning

Not certain if brain changes localized to specific areas, or if interaction between different areas important in causing SpLD Not certain if brain changes localized to specific areas, or if interaction between different areas important in causing SpLD CT / MRI scans not useful CT / MRI scans not useful New research tools: fMRI, PET / SPECT scans New research tools: fMRI, PET / SPECT scans

Functional Imaging in Dyslexia 13 studies: no consistent pattern of hypo- or hyper activation 13 studies: no consistent pattern of hypo- or hyper activation Abnormalities found in multiple areas, sometimes both hemispheres Abnormalities found in multiple areas, sometimes both hemispheres Most common: hypo activation in left temporal lobe during reading tasks Most common: hypo activation in left temporal lobe during reading tasks Some studies: activation increased after remedial therapy for dyslexia Some studies: activation increased after remedial therapy for dyslexia

Attention deficit hyperactivity disorder (ADHD) Affects 8-12% of children Affects 8-12% of children 3 sub-types: 3 sub-types:  ADHD-I: inattention  ADHD-HI: impulsivity and hyperactivity  ADHD-C: have both At risk for poor school performance At risk for poor school performance 20-25% ADHD children have SpLD and vice versa 20-25% ADHD children have SpLD and vice versa

Evaluation Procedure  Letter from School Principal  Multi-disciplinary approach:  Medical / Neurological examination  Vision, Hearing tests  Analysis of school reports  IQ testing (WISC test)  Educational assessment  Psychiatric assessment, if required  Case conference / Final diagnosis  Counseling before Certificate issued  Takes 2-3 wks to complete

Data from LTMGH LD clinic YearTotalSpLDSLMR

At time of diagnosis: Each child’s parents counseled: SpLD: its meaning, treatment, prognosis SpLD: its meaning, treatment, prognosis Importance of remedial education Importance of remedial education Provisions at school examinations and at board examinations in future Provisions at school examinations and at board examinations in future Child and parents to choose whether to avail all available provisions or only some of them Child and parents to choose whether to avail all available provisions or only some of them Choice to be made in consultation with school teachers / remedial teacher Choice to be made in consultation with school teachers / remedial teacher About ADHD if co-morbidity About ADHD if co-morbidity

Remedial Education Cornerstone of treatment of SpLD Cornerstone of treatment of SpLD Should ideally begin early, when child in primary school Should ideally begin early, when child in primary school Special Educator formulates Individual Education Program (IEP) Special Educator formulates Individual Education Program (IEP) Hourly sessions twice / thrice wkly for few yrs Hourly sessions twice / thrice wkly for few yrs

Expensive (Rs / session) Expensive (Rs / session) Most schools do not employ special educators as staff members Most schools do not employ special educators as staff members Children have to necessarily take remedial education from “ private ” special educators Children have to necessarily take remedial education from “ private ” special educators Parents not adequately knowledgeable about remedial education Parents not adequately knowledgeable about remedial education

Role of Provisions SpLD distorts scores causing them to be too low SpLD distorts scores causing them to be too low Provisions formulated to help SpLD children continue in regular mainstream school Provisions formulated to help SpLD children continue in regular mainstream school Provisions function as ‘corrective lens’: distorted array of observed scores back to where they ought to be Provisions function as ‘corrective lens’: distorted array of observed scores back to where they ought to be Provisions serve to "level the play field“: academic performance now commensurate with intellectual ability Provisions serve to "level the play field“: academic performance now commensurate with intellectual ability

Provisions at SSC board examination Extra time of 30 mins for written tests, spelling mistakes overlooked Extra time of 30 mins for written tests, spelling mistakes overlooked Employing writer for children with dysgraphia Employing writer for children with dysgraphia Exemption of 2 nd language, substituting with work experience subject Exemption of 2 nd language, substituting with work experience subject Exemption of standard X mathematics (algebra and geometry), substituting with standard VII mathematics and work experience subject Exemption of standard X mathematics (algebra and geometry), substituting with standard VII mathematics and work experience subject Choice is to be made from a range of 39 work experience subjects Choice 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 Provisions 60 children at SSC examn with provisions compared with performance at last annual school examn before diagnosis of SpLD 60 children at SSC examn with provisions compared with performance at last annual school examn before diagnosis of SpLD Improvement in mean % total marks (63.48 ± 7.86 vs ± 7.23 ) Improvement in mean % total marks (63.48 ± 7.86 vs ± 7.23 ) [mean % difference = 22.53, P < ] [mean % difference = 22.53, P < ] Children who availed exemption of 2 nd language or opted for lower grade mathematics scored better marks Children who availed exemption of 2 nd language or opted for lower grade mathematics scored better marks (P < and P = , respectively) (P < and P = , respectively)

Experiences with Parents Just do not accept diagnosis Just do not accept diagnosis Do not begin remedial education Do not begin remedial education Instead private tuitions Instead private tuitions Omit remedial education early Omit remedial education early Refuse provisions as it restricts future career options (e.g., child who has opted for lower grade of mathematics cannot later have career in engineering) Refuse provisions as it restricts future career options (e.g., child who has opted for lower grade of mathematics cannot later have career in engineering)

Experiences with Schools Regular Awareness Workshops conducted Regular Awareness Workshops conducted School Principals targeted first School Principals targeted first School Teachers sensitized to suspect SpLD School Teachers sensitized to suspect SpLD Initially, many schools uncooperative Initially, many schools uncooperative Implementation of Govt. rules mandatory Implementation of Govt. rules mandatory Cannot detain child if provisions not given Cannot detain child if provisions not given

Wish List Better awareness amongst parents, school authorities, doctors Better awareness amongst parents, school authorities, doctors Remediation Center in every school Remediation Center in every school Standardized psychological and educational tests in all languages Standardized psychological and educational tests in all languages Provisions made available to all SpLD children Provisions made available to all SpLD children Tests to identify children “at risk for SpLD” early Tests to identify children “at risk for SpLD” early Identification of genetic markers for risk of SpLD Identification of genetic markers for risk of SpLD Neuroimaging studies (fMRI and PET) to unravel etiology Neuroimaging studies (fMRI and PET) to unravel etiology

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