1

Specific Learning Disorders

Introduction :
Learning disorders are a group of developmental disorders which are 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.
Child with learning disorder is one who does not meet expectations for academic
performance in school but has intelligence in the normal range.

Definition :
The most accepted definition of Learning disability is the one proposed by National
Advisory Committee on Handicapped Children, USA in 1968 .According to this committee
Specific Learning disability means a disorder in one or more of the basic psychological
processes involved in understanding or in using language, spoken or written, which may
manifest in an imperfect ability to listen, think, speak, read, write, spell or to do mathematical
calculations. The term does not include children who have learning problems which are
primarily the result of visual, hearing, or motor handicaps, of mental retardation, or
emotional disturbance, or of environmental ,cultural, or economic disadvantage
( Grigorenko ,EL;2007). The multi-cultural, multi-linguistic and multi-variant economic
backgrounds unique to India make the implications of these terms difficult to quantify;
neither are they clearly defined. The influence of age of enrolment in school, preschool
exposure to literacy and literacy support at home during the school years also vary in
different parts of this vast country.

Historical aspects :

1
 2

In 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”. In 1925, Dr Samuel Orton (USA) proposed the theory of “specific learning
difficulty”. It was Dr Samuel Kirk (USA) who first used the term “Learning disabilities” to
refer to “children who have disorders in development of language,speech,reading,and
associated communication skills”

Classification :
In ICD-10, Learning disabilities are classified as “Specific developmental disorders of
scholastic skills (SDDSS)” under F 81.The four disorders under this group include : Specific reading
disorder, Specific spelling disorder, Specific disorder of arithmetical skills, Mixed disorder of
scholastic skills. DSM-IV TR has three specific categories under the rubric “Learning disorders”.
These are : Reading Disorder, Mathematics Disorder, Disorder of Written Expression. Specific
learning disorders(SpLD) is the appropriate term as the use of these deficits are in language skills and
not “scholastic” and moreover the presumed etiology of being “developmental”is not needed for
diagnosis .Similarly the use of word “disability” is inappropriate as some children may only have
“difficulty”

Epidemiology :
In a recent review, it was reported that Learning problems occur in about 5% of
school-aged children (Lagae, L; 2008). Dyslexia affects 80% of all those identified as
learning-disabled. The incidence of dyslexia in school children in USA ranges between 5.3-
11.8(7). Although previously it was believed that dyslexia affects boys primarily, recent data
indicate that boys and girls are affected equally. The earlier male preponderance has been
attributed to a referral bias in school-identified children.The degree of overlap between
ADHD and dyslexia has been reported to be 35% (Fletcher JM et al, 1999).
There is paucity of epidemiological studies conducted in India to determine the exact
prevalence of scholastic backwardness, in general, and Specific Learning Disability (SpLD),
in particular (Thacker N;2007). A multilingual India creates even more problems in finding a
universal tool for screening such children (Aftab O and Aslam F, 2006). The incidence of
dyslexia in primary school children in India has been reported to be 2-18%, of dysgraphia
14%, and of dyscalculia 5.5% (Mittal SK et al; 1977, Shah BP et al; 1981; Agrawal et

2
 3

al,1991 and Ramaa S and Gowramma IP ;2002).The delay between symptoms first being
noticed and the child being diagnosed with SpLD in a child guidance clinic was nearly 6
years on average (Karande et al,2005). In an epidemiological study on child and adolescent
psychiatric disorders conducted at Bengaluru, Srinath S etal (2005) reported that the most
common SpLD was Disorder of Written Expression with a prevalence of 1.8%.

Etiology :
Research work has been largely done in the area of Reading disorder (Dyslexia).

Evidence from genetic and neurological studies suggests that dyslexia is a disorder which is

influenced by genetic factors and the underlying deficit is in the language areas of the brain.

Many theories are put forward to explain the etiology of dyslexia. Some of the theories are:

Phonological theory,Cerebellar theory ,Temporal processing deficit theory and

Magnocellular theory. Many genetic studies have identified specific chromosomal loci for

different dyslexia-related phenotypes, which suggests many genes are contributing to

Dyslexia. Loci on 6p21.3, 15q15–q21 and 18p11.2 have been identified as promising

candidate gene regions (Saviour P & Ramachandra NB ;2006) .Certain genetic disorders

have an association with Dyslexia e.g: Turner’s syndrome, Neurofibromatosis Type I

,Phenylketonuria etc.

In normal brain, high percentage of asymmetry is seen in the planum temporale which

is involved in language processing, analysing sounds, naming objects and recalling words.

MRI and post-mortem studies of dyslexic brain indicate the absence of asymmetry of the

planum temporale. Disruptions in white matter connectivity between posterior and frontal

regions have also been found in dyslexic brain. Functional imaging studies like fMRI, PET

and SPECT have failed to show a consistent pattern of hypo or hyper activation.

3
 4

Electrophysiological studies especially of Mismatch negativity (MMN) ,P300 and

N400 have shown some deficits (Habib M;2000)

Clinical features
The common complaints from parents and/or teacher are: writing slowly, cannot
complete classwork and homework, poor handwriting, in exam omits long answer questions,
cannot complete exam paper in time, writing lot of spelling mistakes, reading slowly, reading
word by word, replacing difficult words with words of similar pronounciation, reading
without punctuation, mistakes while doing arithmetic etc

Assessment :
Firstly, a detailed history especially good developmental and schooling history is
mandatory. Information needs to be obtained from parents as well as class teacher. One needs
to carefully exclude other conditions which cause poor school performance viz., ADHD,
depression, conduct disorder, and oppositional defiant disorder. Audiometric and ophthalmic
examinations are needed to rule out hearing and visual deficits. A neurological examination
is needed to rule out conditions like Cerebral palsy, Wilson’s disease etc. In most of the cases
of SpLD, neurological evaluation is normal . There may be some soft neurological signs in
few children. Assessment of the child’s level of Intelligence by measuring IQ can be done
using Standardized IQ tests. One can use Malin’s modification of Wechsler’s Intelligence
Scale for children to calculate Verbal, Performance and Full scale IQ. Usually there will be a
discrepancy between both subscales, Performance IQ being more than Verbal IQ.
After assessment of IQ, the detailed evaluation of learning disorders can be done using
structured instruments like NIMHANS SLD Index ( Kapur et al,1991). NIMHANS SLD
index includes the tests in two levels. Level I is for 5-7 years age group and Level II for 8-12
years. The tests in Level I are:
1) Visuo Motor skills ( Copying of three geometrical figures)
2) Writing of Capital letters
3) Writing of Small letters
4) Writing of an alphabet preceding a specified alphabet

4
 5

5) Writing of an alphabet succeeding the specified alphabet

6) Writing of numbers serially
7) Writing of numbers preceding a specified number
8) Writing of numbers succeeding a specified number
9) Colour cancellation test
10) Visual discrimination
11) Visual memory
12) Auditory discrimination
13) Auditory memory
14) Speech/Language
The tests in Level II are:
1) Number cancellation
2) Reading of English passages
3) Spelling of English words ( including Schonell’s 15 words list)
4) Reading comprehension of English passages
5) Arithmetic subtest
6) Bender Gestalt test for Visuo-spatial abilities
If a child’s performance on any of the academic skills is more than two standards below
the standard he/she is studying currently, it indicates a learning disability. If it is just one
or two standards below it indicates a learning difficulty.

Differential Diagnosis : The following conditions should be kept in mind and ruled out by
meticulous evaluation :
1) Borderline Intelligence
2) Mental Retardation
3) Pervasive developmental disorder
4) Discrepancy between mother tongue and medium of schooling
5) Inadequate facilities for schooling
6) Hearing Impairment
7) Visual Impairment
8) Neurological disorders eg : Myopathy ,Writer’s cramp etc

5
 6

Management :

The management of SpLD is multidimensional. Broadly the following strategies are

useful :

1) Psycho-education of parents and teachers – helps to improve awareness.

2) Remedial Education – There are several approaches depending on the nature of
disorder. The following are some of the common approaches :
For Reading Disorder – Gillingham approach, Programmed reading, Remedial
reading drills, Neurological Impress method, Distar Reading programme etc.
For Writing disorder –Fernald’s Multisensory approach, Handwriting practice
For spelling disorder – Westerman’s Sensory modality preference, cover and write
Method, Schumaker’s Error monitoring exercises.
3) Speech therapy
4) Psychotropic medication for Co-morbidity e.g. : Stimulants or Atomoxetine for
ADHD
5) Options for schooling- e.g. : National open school, Vocational training programmes
6) Provision of certain concessions -exemption from spelling mistakes, availing extra 30
minutes for all written tests, dropping a language and substituting it with work
experience, dropping algebra and geometry and substituting them with lower grade of
mathematics

6
 7

References:

1) Grigorenko EL(2007) Learning Disorders . In : Lewis’s Child and Adolescent

Psychiatry .A Comprehensive Textbook Ed : Martin A and Volkmar FR ,Lippincott
Williams & Wilkins
2) Habib M (2000) .The Neurological basis of Developmental Dyslexia .An overview
and working Hypothesis.Brain,123,2373-2399.
3) Karande S and Kulkarni M (2005) Poor school performance. Indian Journal of
Pediatrics;72:961-7
4) Lagae ,L (2008). Learning disabilities: definitions, epidemiology, diagnosis, and
intervention strategies. Psychiatric Clinics of North America, Dec;55(6):1259-68, vii
5) Ramaa , S and Gowramma ,IP(2002) A systematic procedure for identifying and
classifying children with dyscalculia among primary school children in
India.Dyslexia. Apr-Jun;8(2):67-85.
6) Saviour P and Ramachandra NB (2006) Biological basis of Dyslexia .A maturing
perspective . Current Science,Vol 90,No.2
7) Shah N and Bhat T (2007) Specific Learning Disorders ( Lead Paper) .In : Child and
Adolescent Psychiatry Clinical Practice Guidelines for Psychiatrists in India .Ed: Gautam
S,Avasthi Aand Malhotra S.Indian Psychiatric Society.
8) Srinath S, Girimaji SC, Gururaj G et al(2005) Epidemiological study of child &
adolescent psychiatric disorders in urban & rural areas of Bangalore, India. Indian
Journal of Medical Research 122, July, 67-79
9) Thacker,N (2007) Poor scholastic performance in children and adolescents. Indian
Pediatrics, Jun;44(6):411-2.