Specific learning disabilities

Dr. Jnanendra N Sharma

(The writer can be contacted at drjnanen@gmail.com)

Although for more than hundred years, it has been recognized that seemingly normal children can have impairment of learning to read and write. It was only in 1886, a 14-year-old boy was discovered, who was bright and intelligent but had great difficulty in reading. This condition was termed as ‘congenital word blindness’. The term ‘learning disability’ was first coined in 1962.

Specific learning disabilities (SpLD) are chronic life-long conditions with problems in learning to read, write, spell or do mathematics. Children with SpLD fail to achieve school grade at a level that is commensurate with their intelligence resulting in an impact on self-image, peer and family relationship and social interactions.

Specific learning disabilities (SpLD) is a generic term that refers to a heterogeneous group of neurobehavioral disorders manifested by significant unexpected, specific and persistent difficulties in acquisition and use of efficient reading (dyslexia), writing (dysgraphia) or mathematical abilities (dyscalculia), despite conventional instruction, intact senses, normal intelligence, proper motivation and adequate socio-cultural opportunity.

Characteristics of Dyslexia

Dyslexia is the most common and most comprehensively studied of the learning disabilities. Both sexes are affected equally and affect 5–12% of school children. It is characterized by an unexpected difficulty in reading in children who otherwise possess intelligence, motivation, and opportunities to learn which are considered necessary for accurate and fluent reading.

Children with dyslexia read slowly and hesitantly, follow the words with fingers, mispronounce words and confuse letters. Examples of confusion of letters include ‘bog’ for ‘dog’, inversion of ‘n’ for ‘u’. They are poor at copying from board and skip or add words when reading loud.

There is no single unified theory to explain the cause of dyslexia. It can be both familial and heritable. The exact mechanisms by which genetic factors predispose someone to dyslexia are not clear. However, tests to identify children at risk for dyslexia, at the time of admission to school, are being developed. These would help in early intervention.

Characteristics of Dysgraphia

It is characterized by difficulty in writing. The writing may be very small or large, may be impossible to read. There is use of faulty pressure in writing and written sentences are jumbled with faulty spacing.

Characteristics of Dyscalculia

It is characterized by difficulty in mathematics i.e. calculations, tables and logic. They count numbers on fingers. Mental sums are difficult for these children. They mix up symbols like ‘+’, ‘=’ etc.

Early Diagnosis of SpLD

An early diagnosis is essential to prevent poor school performance and its emotional sequel. In addition, longer the child is with SpLD at any level of severity more difficult is to treat. Hence all children with learning problems in school should be evaluated for SpLD.

Identification of SpLD is difficult during preschool years. A conclusive diagnosis is not possible until the age of 8 – 9 years. The red flag signs for dyslexia are:

(i) History of language delay

(ii) Not attending to sounds of words (e.g. trouble playing rhyming games with words or confusing words that sound alike)

(iii) A positive family history.

Evaluation of Suspected SpLD

The child with a learning problem needs a multidisciplinary assessment by a pediatric neurologist, counselor, clinical psychologist, special educator and a child psychiatrist. Everyone has their own part to play to arrive at a diagnosis of SpLD.

The pediatric neurologist will exclude other causes of poor school performance. The causes include medical causes (e.g. hypothyroidism, chronic lead poisoning), neurological causes (e.g. cerebral palsy), and behavioral causes (e.g. depression, conduct disorders, opposition defiant disorders etc.).

An audiometric and ophthalmic examination should be done to rule out hearing or visual deficit as the cause of the learning problem.

The counselor rules out whether any environmental deprivation due to poor home or school environment, or any emotional problem due to stress at home or school, is primarily responsible for the child’s poor performance at school.

The clinical psychologist will conduct intelligence tests and rule out mental retardation as a cause of poor school performance.

The special educator will assess the child’s academic achievements on the basis of standard educational tests and assess child’s performance in areas viz. reading, spelling, written language and mathematics. An academic achievement of two years below child’s actual school grade placement or chronological age is considered diagnostic of SpLD.

The child psychiatrist plays an important role in confirmation of diagnosis of ADHD, a comorbid condition found in around 12–24% of children with SpLD and also helps in confirmation of diagnosis of depression, behavioral problems as a cause of the learning problem.

Management

Management of child with SpLD includes primarily remedial education and accommodations, counselling and guidance, and treatment of associated problems.

Remedial education is the cornerstone of therapy. It includes understanding of the strengths and weaknesses and providing an individualized educational plan.

Role of accommodation is to help the child with SpLD to cope up in regular mainstream school. The treatment of dyslexia in students in high school, college is typically based on accommodation rather than remedy. Accommodations include exemption from spelling mistakes, dropping a language and substituting it with work experience subject, dropping algebra and geometry and substituting them with a lower grade of mathematics.

Other helpful accommodations may be use of laptops, computers with spelling checkers, tape recorders in the classrooms, recorded books, and access to lecture notes, tutorial classes and separate quiet room for taking tests.

Outcome

With appropriate remedial education and accommodations, most children achieve academic competence and complete their education in regular mainstream school. Some children need to continue education in special schools as they are unable to cope up in mainstream schools. The outcome however depends on the severity of disability, age or grade when remedial education was started, length and continuity of treatment, presence or absence of associated emotional problems, parental and school support.