1.

Discuss the pathophysiology of Learning Disability and the diagnostic tools

Learning disorders are considered a type of neurodevelopmental disorder.

NEURODEVELOPMENTAL DISORDER:
Neurodevelopmental disorders are neurologically based conditions that appear early
in childhood, typically before school entry. These disorders impair development of
personal, social, academic, and/or occupational functioning and typically involve
difficulties with the acquisition, retention, or application of specific skills or sets of
information. The disorders may involve dysfunction in attention, memory, perception,
language, problem-solving, or social interaction. Common neurodevelopmental disorders
include attention-deficit/hyperactivity disorder, autism spectrum disorders, and intellectual
disability.

LEARNING DISABILITY:

Learning disability (LD) refer to several disorders that may affect the acquisition,
organization, retention, comprehension, or the use of both verbal or nonverbal information.

As per the Diagnostic and Statistical Manual of Mental Disorders, Fifth Edition (DSM-5), ,
the following symptoms are comprised as part of the diagnosis of a specific learning disorder:

1. Constant struggles with arithmetic, writing, reading, or mathematical reasoning skills

throughout the school years. 

2. Must have current below-average grade parameters in suitable linguistic and cultural tests
in the subject of writing, reading, and mathematics. 

3. The patient's learning difficulties must begin during the school years

4. It cannot be explained by any neurological, developmental, motor, or sensory (hearing or

vision) disorder and should remarkably impede academic achievement, activities of daily
living, or occupational performance.

CLINICAL CRITERIA:

Diagnosis of learning disorders is made clinically based on criteria in DSM-5, and requires
evidence that at least one of the following has been present for ≥ 6 months despite targeted
intervention:

• Inaccurate, slow and/or effortful word reading

• Difficulty understanding the meaning of written material.
• Difficulty spelling.
• Difficulty writing (eg, multiple grammar and punctuation errors; ideas not expressed
clearly).
• Difficulty mastering number sense (eg, understanding the relative magnitude and
relationship of numbers; in older children, difficulty doing simple calculations).
• Difficulty with mathematical reasoning (eg, using mathematical concepts to solve
problems).

COMMON TYPES OF LD:

The classification of the disorder is based on by either the type of information processing
affected by the disability or by the specific difficulties caused by a processing deficit (a)
Based on information processing. (b) By function impairment

A. BASED ON INFORMATION PROCESSING:

The disability could be in any of the four stages of information processing used in
learning: input, integration, storage and output.

I INPUT: Difficulties with visual perception can cause problems with recognizing the shape,
position, or size of items seen. There could be problems with temporal perception. Auditory
processing difficulties could make it difficult to screen out competing sounds.

II. INTEGRATION : This has to deal with the process of categorizing, placing in sequence
or placing into previous learning. Students with problems may not be able to memorize
sequence of information. A poor vocabulary may result in problems with comprehension.

III. STORAGE : The student may not have short-term memory or working memory, or long
term memory. This may make it difficult to learn new material without more repetitions than
usual. Difficulties with visual memory make the child it difficult to learn spellings.

IV. OUTPUT : The brain outputs information through words or muscle activity. Difficulties
with language output could create problems with spoken language or when using the written
language. Problems with motor activity (gross or fine motor), may cause stumbling, falling,
bumping, bad handwriting, difficulty in tying shoelaces and the like.

B. BY FUNCTION IMPAIRED:

The deficit in any area of information processing can manifest in a variety of specific
learning difficulties.

I. DYSLEXIA: A reading disability can affect any part of the reading process, including
difficulty with accurate or fluent word recognition, or both, word decoding, reading rate,
prosody (oral reading with expression), and reading comprehension.

II. DYSGRAPHIA: is the writing disorder. Writing skills are substantially below those
expected, based on the chronological age, measured intelligence and age appropriate
education. There will be problems in grammatical and punctuation errors and poor paragraph
organization, multiple spelling errors and penmanship.

III. DYSCALCULIA: It involves difficulties in learning maths concepts, memorizing math

facts, organizing numbers and their organization.

IV. NONVERBAL LD : It represents another type of learning difficulty in which individuals

demonstrate adequate vocabulary, verbal expression, or reading skills, but present difficulties
with certain nonverbal activities (e.g., problem-solving, visual-spatial tasks and reading body
language, recognizing social cues).

ETIOLOGY

The main factor attributed to learning disabilities is assumed to be neurobiological in origin,

secondary to an identified brain pathology. Furthermore, both hereditary and environmental
factors have been suggested. Learning disorders may be congenital or acquired. Other
possible causes include

• Maternal illness or use of toxic drugs during pregnancy.

• Complications during pregnancy or delivery (eg, spotting, toxemia, prolonged labor,
precipitous delivery).
• Neonatal problems (eg, prematurity, low birth weight, severe jaundice, perinatal
asphyxia, postmaturity, respiratory distress).

Potential postnatal factors include exposure to environmental toxins (eg, lead), central
nervous system infections, cancers and their treatments, trauma, undernutrition, and severe
social isolation or deprivation.

ETIOLOGICAL MODELS OF LEARNING DISABILITY

The etiological factors in learning disability are explained by five models.
A. THE DIFFERENCE MODEL:
This model states that individual differences in cognitive ability tend to be normally
distributed throughout a given population and learning difficulties result from the natural
occurrence of poorly developed cognitive skills.

B. THE DEFICIT MODEL:

This model postulates learning difficulties that are associated with organic conditions that
interfere with learning. These may include mixed cerebral dominance, maldevelopment or
disease of the brain, vestibular difficulties and ocular difficulties.

C. THE DELAY MODEL:

In this model, learning difficulties are associated with immaturity in development which
eventually will be resolved and academic skills will develop.

D. THE DISRUPTION MODEL:

This postulates that, extraneous factors such as anxiety or depression are disrupting the
learning process.

E. THE PERSONAL-HISTORICAL MODEL:

This model suggests that the student has not acquired the basic skills needed or learning
because of environmental factors such as failure in the teaching or learning process.

These models offer various explanations for learning disability and no single model
could explain the disabilities completely. The models are not mutually exclusive and
elements of each cause may be associated with other causes. This would be indicative that
learning disability is multifactorial.

PATHOPHYSIOLOGY:

Some studies of the brain of patients with dyslexia have shown scattered small
malformations mainly on the left cerebral hemisphere at the cerebral cortex. There has been a
probable hypothesis that a disorder of corticostriatal systems may result in problems in
learning language.

DIAGNOSTIC EVALUATION:

 Cognitive, educational, medical, and psychologic evaluations

 Clinical criteria

Children with learning disorders are typically identified when a discrepancy is

recognized between academic potential and academic performance. Speech and language,
cognitive, educational, medical, and psychologic evaluations are necessary for determining
deficiencies in skills and cognitive processes. Social and emotional-behavioral evaluations
are also necessary for planning treatment and monitoring progress.

The medical team will work on ruling out hearing and vision impairments and establishing
that the learning deficits are not due to limited access to appropriate guidance. Also, the
pediatrician can work in the diagnosis and treatment of associated developmental or
behavioral disorders, such as attention deficit hyperactivity disorder or autism, in addition to
recognizing psychosocial factors to the child’s difficulties. 

Blood, urine, and imaging studies are usually not indicated or useful for the evaluation of
learning disabilities. Exceptions include neurological findings suggestive of a focal brain
lesion, skin lesions suggestive of a neurocutaneous syndrome, and findings on physical exam
or past medical history that would suggest nutritional disorders or syndromes that could have
a genetic or metabolic cause. Hearing and vision screening should always be documented. 

The formal diagnostic process to know the presence and extent of a learning disability is
domain-specific academic and cognitive testing. This evaluation tests a child’s cognitive
abilities, the areas of language processing, attention, memory, and nonverbal reasoning, in
addition to specific academic achievement in core areas, such as mathematics, reading, and
written expression. 

Some of the most commonly used tests for the evaluation of suspected learning disabilities
are the

- Woodcock-Johnson-III and Wide Range Achievement Test to evaluate academic

achievement

- Adaptive Behavior Assessment System-II and

 - Vineland Adaptive Behavior Scale-II to assess adaptive behavior

- Conners Rating Scale

- ADHD Rating Scale-IV

- NICHQ Vanderbilt Parent and Teacher Assessment Scales to evaluate for attention
and hyperactive disorders

- Wechsler Intelligence Scales for Children—Fourth Edition (WISC-IV) for evaluation

of general cognition

- Achenbach Child Behavior Checklist (CBCL) for assessment of general behavior

- Clinical Evaluation of Language Fundamentals (4th Ed.) (CELF) for language

evaluation

- Beery Test of Integration (5th Ed) for visual-motor evaluation. 

The usual criteria for diagnosing reading disability (RD) include deficient word
recognition and decoding skills identified through specific testing. Other evaluations will also
assess spelling, reading comprehension, and fluency; some will test the deficiencies in
phonologic processing in reading disability

Recently the Response to Intervention (RTI) has been used as a valid standard approach
to the diagnosis of learning disability. This model is a process of evaluation that is followed
by a restorative instruction in the child’s specific area of deficits during a specific period
before reassessing. The assessment- instruction-assessment model is progressive and
intensive educational support. It can aid in differentiating the lack of proper instruction from
true learning disability by demonstrating if there is an improvement with a small increase
intensity of instruction or if it requires repeated cycles of RTI, with the result of a very
specified and personalized instructional program.

THE TESTS THAT PROFESSIONALS USE:

There are various tests commonly used to diagnose dyslexia and language disability
from preschool through adulthood.
ELEMENTARY (9-11 YEARS)

LANGUAGE: ORAL AND WRITTEN:

 Assessing Linguistic Behaviors Communicative Intentions Scale (ALB)

 Clinical Evaluation of Language Fundamentals, Fifth Edition (CELF-5)
 Clinical Evaluation of Language Fundamentals-Preschool, Second Edition (CELF-
Preschool 2)
 Comprehensive Assessment of Spoken Language (CASL)
 Developmental Indicators for the Assessment of Learning (DIAL-3)
 Expressive One-Word Picture Vocabulary Test, Fourth Edition (EOWPVT-4)
 MacArthur Communicative Development Inventories-Words and Gestures (CDI)
 Oral and Written Language Scales: Written Expression (OWLS Written Expression)
 Peabody Picture Vocabulary Test, Fourth Edition (PPVT-4)
 Preschool Language Scale, Fourth Edition (PLS-4)
 Receptive-Expressive Emergent Language Test, Third Edition (REEL-3)
 Receptive One-Word Picture Vocabulary Test (ROWPVT)
 Test of Auditory Comprehension of Language, Third Edition (TACL-3)
 Test of Auditory Processing Skills 3rd Edition (TAPS-3)
 Test of Early Written Language 2 (TEWL-2)
 Test of Narrative Language (TNL)
 Test of Pragmatic Language (TOPL)
 Test of Written Language, Third Edition (TOWL-3)
 Test of Written Spelling, Fifth Edition (TWS-5)
 The Word Test 2: Elementary
 The Word Test 2: Adolescent

TESTS USED TO EVALUATE LANGUAGE AND COMMUNICATION SKILLS:

Apraxia Battery
Auditory Skills Battery
Brown-Carlson Listening Comprehension
Test Clinical Evaluation of Language Functions-Diagnostic Battery
Carrol-Sapon Auditory Discrimination Tests
Detroit Tests of Learning Aptitude (DTLA)
Dictated paragraphs
Goldman-Fristoe-Woodcock Test of Auditory Discrimination
Illinois Tests of Psycholinguistic Abilities (ITPA)
Informal notetaking
Informal reading inventory
Informal writing inventory
Lindamood Auditory Conceptualization Test
Malcomesius Specific Language Disability Test
Modern Language Aptitude Test (selected subtests)
Morrison-McCall Spelling Scale
Peabody Individual Achievement Test (PIAT)
Spache Diagnostic Reading Scales
Test of Adolescent Language (TOAL)
Test of Written Language (TOWL)
Wechsler Adult Intelligence Scale-Revised (selected subtests)
Wepman Auditory Discrimination Test
Wide Range Achievement Test (WRAT) & WRAT-R
Woodcock-Johnson Psycho-Educational Battery
Woodcock Reading Mastery Tests
READING:

 Comprehensive Test of Phonological Processing, Second Edition (CTOPP-2)

 The Diagnostic Assessments of Reading with Trial Teach Strategies (DAR-TTS)
 Qualitative Reading Inventory, Fifth Edition (QRI-5)
 Woodcock Reading Mastery Tests-Revised (WRMT-R)
 Gray Oral Reading Tests, Fifth Edition (GORT-5)
 Gray Silent Reading Tests (GSRT)
 Rapid Automatic Naming and Rapid Alternating Stimulus Tests
 The Nelson- Denny Reading Test of Vocabulary, Reading Comprehension, and
Reading Rate
 Stanford Diagnostic Reading Test (SDRT)
 WJPEB
 WRAT-R
 Woodcock Reading Mastery Test
 Nelson-Denny Reading Test
 Informal Reading Assessments

TESTS USED TO EVALUATE MATH SKILLS:

WRAT/WRAT-A
WJPEB II
Key-Math
Stanford Diagnostic Math Test
ACHIEVEMENT:

 Kaufman Test of Educational Achievement, Second Edition Comprehensive Form

(KTEA-II)
 Wechsler Individual Achievement Test, Second Edition (WIAT-II)
 Woodcock Johnson-III Tests of Achievement (WJ III ACH)

INTELLIGENCE:

 Kaufman Assessment Battery for Children, Second Edition (KABC-II)

 Stanford-Binet Intelligence Scales for Early Childhood, Fifth Edition (Early SB5)
 Wechsler Preschool and Primary Scale of Intelligence, Third Edition (WPPSI-III)
 Woodcock-Johnson III Tests of Cognitive Abilities (WJ III COG)
 McCarthy Scales of Children’s Abilities (MSCA)
 Wechsler Intelligence Scale for Children, Fourth Edition Integrated (WISC-IV
Integrated)
 WAIS-R
 RAVENS
 WJPEB
 PPVT-R
  TONI

ARTICULATION: 

 Arizona Articulation Proficiency Scale, Third Revision (Arizona-3)

 Goldman-Fristoe Test of Articulation, Second Edition (GFTA-2)
 Kaufman Speech Praxis for Children (KSPT)
 Khan-Lewis Phonological Analysis (KLPA-2)
 Photo Articulation Test – 3rd Edition (PAT-3)

SOCIAL:

 Ages and Stages Questionnaires: A Parent-Completed, Child-Monitoring System,

Second Edition (ASQ)
 Vineland Adaptive Behavior Scales, Second Edition (Vineland-II)
 Test of Problem Solving 3: Elementary (TOPS-3)

MOTOR SKILLS :

 Bayley Scales of Infant and Toddler Development-Third Edition (Bayley-III)

 The Beery-Buktenica Developmental Test of Visual-Motor Integration, 5th Edition
(Beery VMI)
 Peabody Developmental Motor Scales, Second Edition (PDMS-2)

TESTS USED TO EVALUATE VISUAL PERCEPTION / PROCESSING:

Bender-Gestalt
WAIS-R Subtests
WJPEB Subtests
Beery Test of Visual Motor Integration

ASSESSMENTS IN INDIA:
The National Institute of Mental Health and Neurosciences (NIMHANS), Bangalore
has developed the index to assess children with LD
There are two levels of this index. They are:
Level I for children 5-7 years and
Level II for 8-12 years.
The index comprises of the following tests:
a. Attention test (Number cancellation).
b. Visuo-motor skills (the Bender Gestalt test and the Developmental test of Visuo
– Motor integration).
c. Auditory and Visual Processing (discrimination and memory).
d. Reading, writing, spelling and comprehension.
e. Speech and Language including Auditory behaviour (Receptive Language) and Verbal
expression.
f. Arithmetic (Addition, subtraction, multiplication, division and fraction)

Procedure for assessment of Specific Learning Disability involves the following:

a. Neurological assessment.
b. Vision and Hearing tests.
c. Analysis of school progress report.
d. I.Q. test.
e. Educational assessment.
f. Psychiatric assessment.
g. Case conference.
h. Counseling.
Management of LD is a team work. The persons involved in efficient assessment and
management include
Clinical Psychologist Physician
School Psychologist
Educational Psychologist
Neuropsychologist
Psychometrist
Educational Specialist
School Counselor
Vocational Counselor
Social Worker
Speech and Language Specialist
Occupational Therapist
Psychiatrist