LEARNING DISABILITY

DEFINITION:

Learning disability (LD) is a neurological developmental disorder manifested by significant disabilities

in the acquisition, organization, retention, comprehension, or the use of both verbal and non verbal
information.[1][2] It can interfere with oral language (i.e. listening, speaking, understanding), reading
(i.e. decoding, phonetic knowledge, word recognition, comprehension), writing (i.e. spelling and written
expression), mathematical abilities (i.e. computation, problem solving), reasoning, coordinated
movements, perceiving, thinking, remembering, learning, language processing, phonological processing,
visual spatial processing, processing speed, memory & attention organizational skills, social perception,
social interaction, perspective taking and executive functions (e.g. planning & decision making).[2][3][4]

EPIDEMIOLOGY:

Studies have reported one percent to nineteen percent of school going children in India have LD. The
mean from the year 2000 to 2017 shows 10 percent of children in India have LD. [5] Among the
subtypes, the prevalence of dyslexia is 4.58%, dysgraphia 0.2%, dyscalculia 0.63%, and combined
learning disability is 7.5% respectively in school children.[7] Boys (9.6%) were significantly more
affected than girls (4.9%). Risk was significantly higher in students of government schools (12.1%)
than private schools (2.2%).[6] Risk factors include prematurity, cesarean section, congenital
hydrocephalus, meningitis, encephalitis, delayed speech, family history of SLD, poverty, prenatal
exposure to alcohol & radiation, chemotherapy & intrathecal corticosteroid treatments, TBI, and other
neurodevelopmental disorders. [7][8][9]

ETIOLOGY AND PATHOGENESIS:

Genetic and environmental factors may contribute to learning disability.[10] Dietary factors also have a
part in the development of intelligence because of the link between breast feeding (essential fatty
acids) and higher IQ.[11] Learning disability is also associated with increased maternal age, but only
in mothers with low education.[12]

Mutations in X-linked genes account for higher rate of learning disability in males.[13] Imprinting may
result in differential expression of symptoms in conditions affecting the same portion of the genome
but with discrepant phenotypes (such as Prader-Willi and Angelman’s syndromes).[9] Trinucleotide
repeat expansion is a mechanism underlying some specific behavioural phenotype syndromes, including
fragile X. Rearrangements involving subtelomeric, regions account for 10% of Idiopathic LD.[14][15]
Specific chromosomal and defective gene syndromes which include fragile X, 22q11 deletion syndrome,
and the various gonosomal aneuploidies, such as Klinefelter’s syndrome are common cause of LD.[16]

Data showing a high rate of abnormal dermatoglyphics in people with learning disability suggested that
environmental factors acting early in development, or interactions between genotype and environment,
could have a causative role in some cases.[17] Low-dose chronic exposure to lead and methylmercury
poisoning can cause learning disability. Others proven neurotoxicants include alcohol, tobacco smoke,
pesticides, thalidomide, valproic acid, polychlorinated biphenyls and dioxins.[18][19]

EVALUATION AND DIAGONOSIS:

Learning disability is evaluated beginning with the exclusion of both organic and functional differential
diagnoses. It is diagnosed under the guidelines set by Diagnostic and Statistical Manual of Mental
Disorders (DSM). Evaluation should synthesize developmental, medical, familial, and educational
histories of the patient.

As per the DSM-5:

There are 4 criteria which need to be fulfilled to diagnose as learning disability

Criterion A: Difficulties in learning and using academic skills, as indicated by presence of one of the
following symptoms that have persisted for at least 6 months.

 Inaccurate or slow and effortful word reading.

 Difficulty understanding the meaning of what is read.
 Difficulties with spelling.
 Difficulties with written expression.
 Difficulties mastering number sense, number facts, or calculation.
 Difficulties with mathematical reasoning.

Criterion B: The academic skills are lower than expected for the individual’s chronological age and
significantly interfere with academic or occupational performance, or with activities of daily living, as
confirmed by standardized achievement measure and comprehensive clinical measure.

Criterion C: Learning difficulties begin during school-age but may manifest only when academic skills
exceed the individual’s limited capacities.

Criterion D: The learning difficulties are not better accounted for by intellectual disabilities,
uncorrected visual or auditory acuity, other mental or neurological disorders, psychosocial adversity,
lack of proficiency in the language of academic instruction, or inadequate educational instruction.

Coding note:

315.00 (F81.0) Dyslexia - Impairment in reading

Word reading accuracy

Reading rate or fluency
Reading comprehension
Word recognition
Decoding
Spelling

315.2 (F81.81) Dysgraphia - Impairment in written expression

Spelling accuracy
Grammar and punctuation accuracy
Clarity or organization of written expression

315.1 (F81.2) Dyscalculia - Impairment in mathematics

 Number sense
Memorization of arithmetic facts
Accurate or fluent calculation
Accurate math reasoning

Severity:

Mild: Some difficulties learning skills in one or two academic domains, but of mild enough
severity that the individual may be able to compensate or function well when provided with
appropriate accommodations or support services, especially during the school years.

Moderate: Marked difficulties learning skills in one or more academic domains, so that the
individual is unlikely to become proficient without some intervals of intensive and specialized
teaching during the school years. Some accommodations or supportive services at least part of the
day at school, in the workplace, or at home may be needed to complete activities accurately and
efficiently.

Severe: Severe difficulties learning skills, affecting several academic domains, so that the individual
is unlikely to learn those skills without ongoing intensive individualized and specialized teaching
for most of the school years. Even with an array of appropriate accommodations or services at
home, at school, or in the workplace, the individual may not be able to complete all activities
efficiently.

COMORBIDITY

Learning Disability occurs along with behavioural phenotype syndromes (e.g. Down’s syndrome,
22q11-deletion, fragile X, Prader-Willi, Angelman’s, Rett’s, and Smith-Magenis syndromes, and the
fetal alcohol syndrome) causing behaviors like stereotyping; self-injuring; violent destructive;
hyperactivity; and temper tantrums, neurodevelopmental disorders (e.g. ADHD, communication
disorders, developmental coordination disorder, autistic spectrum disorder), mental disorders (e.g.
Schizophrenia, anxiety disorders, depressive disorders, eating disorders, conduct disorder and bipolar
disorders) or with other medical conditions (e.g. Epilepsy, Cerebral palsy, Hypothyroidism, Cancers –
Stomach; gallbladder; esophagus; testis; thyroid and connective tissue, Tuberous sclerosis, oral problems,
visual impairment - cataract and keratoconus, and hearing deficit).[1][9]

MORTALITY

The Learning Disability Mortality Review (LeDeR) looked into the deaths of people with a learning
disability aged 4 years and over between 1 July 2016 and 31 December 2018, was notified of 4302
deaths and reviewed 1081 of them. The median age of death for males with a learning disability was
60 years compared with 83 for men in the general population. While the median age of death for
females with a learning disability was 59 years compared with 86 for females in the general
population.[20] Numerous subsequent reports have shown that people with a learning disability
experience premature deaths, which could have been avoided with adequate healthcare provision.[21]
[22][23][24][25][26][27]. A minority of cases in the death reports in two London districts citied the
learning disability as directly contributing to the cause of death. Certificates rarely specified the cause
of the learning disability with the most common causes or associated conditions mentioned being
Down syndrome, cerebral palsy, incontinence, problems with mobility, respiratory disease, microcephaly,
and residence in hospital & services provided.
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