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https://doi.org/10.1007/s12098-019-03130-z
ORIGINAL ARTICLE
Received: 22 June 2019 / Accepted: 19 November 2019 / Published online: 21 December 2019
# Dr. K C Chaudhuri Foundation 2019
Abstract
Objectives To study the proportion of children of age 5 to 7 y at risk of specific learning disability (SLD) and to analyse the socio-
demographic risk factors.
Methods A school based cross-sectional study was conducted in six schools in Puducherry. Four hundred eighty students were
enrolled and study was conducted in a triphasic approach. Phase I- Screening by teachers using SLD-SQ (Specific Leaning
Disability – Screening Questionnaire); Phase II- Vision, hearing, and Intelligence Quotient (IQ) assessment were done in students
screened positive with SLD-SQ and those with vision or hearing impairment and subnormal intelligence were excluded; Phase III-
Remaining children were subjected to NIMHANS SLD index (Level I profile).
Results Of the 480 enrolled students 109 were screened positive with SLD-SQ. Twelve students were excluded in Phase II. Remaining
97 evaluated were evaluated with NIMHANS SLD index and 36 (7.5%) were screened positive. Boys (9.6%) were significantly more
affected than girls (4.9%). Similarly, risk was significantly higher in students of government schools (12.1%) than private schools (2.2%).
Ignoring punctuation and capitals was the commonest problem in SLD-SQ whereas, dysgraphia was most common in NIMHANS index.
Conclusions The present study shows though SLD is highly prevalent and remains undiagnosed due to lack of awareness among
teachers and parents. Since early intervention leads to better outcomes, Universal screening should be made mandatory and
remedial teaching centres made available, accessible and economical.
adopting lottery method of simple random sampling, 6 Phase II and III were done by a single investigator to avoid
schools were selected. Sample size was calculated as 480 bias. IQ assessment was done by clinical psychologist of au-
taking prevalence of SLD as 10% [9], confidence interval thors’ Institute.
95%, absolute precision 3% and 20% non-response rate. Data analysis was done using SPSS 24.0 software.
After obtaining clearance from Institutional Ethics Variables such as socio-demographic characteristics, item
Committee and permission from Deputy Director of wise analysis of SLD-SQ, analysis of NIMHANS index
School Education, the study was initiated. All students of were represented in tables showing frequency and percent-
age 5 to 7 y from the selected schools whose parents age. Logistic regression analysis was done to assess the
consented were included in the study. impact of gender, school sector and socio-economic status
The study was conducted with a tri-phasic approach: on risk of SLD.
Phase I – Socio-demographic details of all students were
collected. Socio economic status was classified using
Modified B.G. Prasad classification (2018) [10]. Specific
learning disabilities – screening questionnaire (SLD-SQ) Results
was administered on all the enrolled students with the
help of the teachers. SLD-SQ was designed and standard- The present study was conducted from September 2016
ized by Dr. Uday K Sinha at Institution of Human through October 2018. Four hundred ninety two students of
Behaviour and Allied Sciences, copyrighted at 2015 by age 5–7 y studied in the selected schools. Twelve students
psychomatrix; permission for its use was obtained from were excluded since parents did not give consent. Figure 1
the author. A cut-off score of four or more was considered shows the flow of subjects in the study. Majority of them
indicative of possibility of SLD. Sensitivity and specific- 225(46.9%) were 6 y of age with 53.8% (258) boys and
ity of questionnaire is 0.83 and 0.77 respectively for a 46.3% (222) girls. Table 1 shows socio-demographic details
cut-off of four [11]. of students.
Phase II – Children screened positive with SLD-SQ, In Phase I, 109 (22.7%) children had a SLD-SQ score of
underwent physical examination (for serious ailments that more than four suggesting possibility of having SLD of which
might intrude with academic performance), vision, hearing 74 (67.9%) were boys and 35 (32.1%) were girls. This shows
and Intelligence Quotient assessment. higher screened positive male children, compared to female
Vision assessment was done using Snellen’s chart. Visual children. In item wise analysis of SLD-SQ, ignoring punctu-
acuity less than 6/60 was considered abnormal which is cut- ation and capitals was the commonest problem seen in
off for low vision as per ICD 10 [12]. 174(36.3%) of the students, followed by ineligible writing
Hearing assessment was done using Tuning fork 512 Hz by 133(27.7%). Table 2 shows item wise analysis of SLD-SQ.
Rinne’s and Webers test. Sensitivity and specificity was 87% In Phase II, Out of 109 SLD-SQ screened positive stu-
and 100% respectively. Hearing was considered impaired if dents, 9 had subnormal intelligence, 2 had hearing impair-
either of the test was abnormal [13]. ment, 1 had visual impairment and were excluded.
IQ assessment was done using Seguins Form Board. It is Remaining 97 children were assessed with NIMHANS
a performance based tool that assesses the visuo-motor
skills, eye-hand coordination, visual and spatial perception,
Total number of students of age 5-7 y in selected
cognition speed and accuracy in performing skills. IQ of 90
schools (n=492)
measured for chronological age was considered cut-off for
12 excluded since parents did not give consent
normal. Correlation with other tests like Malins Intelligence
scale for Indian Children and Vineland Social Maturity
Total number of students included in the study (n=480)
Scale ranges from 0.31–0.50 [14].
Children who had visual or hearing impairment or subnor-
mal intelligence were excluded from further evaluation. Phase I – Screened with SLD-SQ by teachers
Phase III – NIMHANS SLD index (Level I profile) 109 screened positive
was administered to children who cleared Phase II assess-
Phase II – Visual impairment (n=1), Hearing impairment
ment of the study. It consists of 8 components: Attention, (n=2), Subnormal intelligence (n=9)
Visual discrimination, Visual memory, Auditory discrimi-
nation, Auditory memory, Speech and Language, 12 excluded
Visuomotor skills and Writing skills. Any child less than
8 y who doesn’t perform adequately is considered to have Phase III – NIMHANS SLD index – 36 students
identified at risk of SLD
specific learning difficulty or at risk for SLD. Test retest
reliability is 0.53 (p < 0.001) [15]. Fig. 1 Flow of subjects in the study. SLD Specific learning disability
96 Indian J Pediatr (February 2020) 87(2):94–98
Table 1 Socio-demographic details of students (n = 480) Table 3 Item wise analysis of NIMHANS index (Level I profile) (n =
97)
Characteristics n (%)
S. No Items n (%)
Age (in years)
5y 91 (19) 1. Writing skills 35 (36.1)
6y 225 (46.9) 2. Visual discrimination 13 (13.4)
7y 164 (34.2) 3. Auditory behavior 12 (12.4)
Sex 4. Auditory memory 10 (10.3)
Boys 258 (53.8) 5. Auditory discrimination 9 (9.3)
Girls 222 (46.3) 6. Visual discrimination 6 (6.2)
School sector 7. Attention 5 (5.2)
Government 255 (53.1) 8. Visuomotor skills 3 (3.1)
Private 225 (46.9) 9. Verbal language expression 0
Socio-economic status
n No. of students evaluated with NIMHANS SLD index
Class I (Upper class) 8 (1.7)
Class II (Upper middle class) 62 (12.9) risk, yet there was no statistical significance (p 0.48).
Class III (Middle class) 241 (50.2) Comparing school sector to SLD risk status, 12.1% children
Class IV (Lower middle class) 141 (29.4) from government schools were at risk but only 2.2% from
Class V (Lower class) 28 (5.8) private schools were at risk. The association was found to be
statistically significant (p 0.000) (Table 4).
n No. of students enrolled in the study
SLD index (Phase III) and 36 students (7.5% of study pop- Discussion
ulation) were found to be at the risk of SLD.
In item wise analysis of NIMHANS SLD index, most of The present study was conducted in six schools in
the affected children had difficulty in writing skills puducherry. Three government and three private schools
[35(36.1%)], followed by impaired visual discrimination were included to study the differences in prevalence and risk
[13(13.4%)], poor auditory behavior [12(12.4%)] and inade- factors. Age group 5 to 7 y was chosen since the age of
quate auditory memory [10(10.3%)]. Table 3 shows item wise identification plays a major role in outcome of the child.
analysis of NIMHANS index. The screening and assessment tools used were SLD-SQ
Analysing the association of socio-demographic factors and NIMHANS SLD index respectively. These tools are
with risk of developing SLD, it is evident that gender has recommended by the recent Indian Academy of Pediatrics
statistically significant association (p 0.02) with 9.6% of boys (IAP) consensus on evaluation and management of learning
being affected compared to 4.6% girls. In socio-economic disability [16].
grounds, 8.3% children from lower socio-economic status In the present study, the proportion of children at risk of devel-
(SES) were at risk while only 1.6% from high SES were at oping specific learning disability was found to be 7.5%. This
Gender
Boys (n = 258) 25 (9.6%) 233 (90.3%) 0.407 0.190–0.871 0.02
Girls (n = 222) 11 (4.9%) 211 (95.1%)
Socio-economic status
High (Class I, II, III) 1 (1.6%) 59 (98.3%) 1.33 0.593–3.006 0.485
(n = 60)
Low (Class IV, V) 35 (8.3%) 385 (91.6%)
(n = 420)
School sector
Private (n = 225) 5 (2.2%) 220 (97.8%) 0.179 0.071–0.450 0.000
Government (n = 255) 31 (12.1%) 224 (87.8%)
finding is closely in consistence with a study conducted at Andhra Bandla et al. stated a high prevalence rate of SLD among high
Pradhesh in 2017 by Bandla et al. (6.6%) [17]. However, it is and upper middle socio-economic class [7, 17]. The study
relatively low when compared to studies conducted by settings in these studies were from private remediable clinics
Mogasale VV (15.17%) at Karnataka in the year 2014 and whose parents are expected to be economically affordable.
Sridevi et al. (19%) in Hyderabad (2015) [5, 18]. Analyzing var- With item wise analysis of SLD-SQ, ignoring punctuation
ious other studies, range of SLD prevalence can be given as 6.6% and capitals was the commonest problem, followed by ineli-
to 19% in South India [5, 17–20] and 1.58% to 12.8% in north gible writing. Padhy et al. also used SLD-SQ to screen for
India [2–4, 21–23]. These studies had heterogeneity in sample SLD [2]. They found missing out words or sentences while
size, sampling technique, screening tool used, method used for reading to be the commonest issue followed by, misplacing
assessing SLD, study setting, study population and environmental letters or words while reading or writing.
background which explains variation in the prevalence figures. With item wise analysis of NIMHANS index, 36.1% had dif-
The present study showed statistically significant gender dif- ficulty in writing (dysgraphia), followed by impaired visual dis-
ference with boys (9.6%) being affected twice more than girls crimination in 13.4% and poor auditory behavior in 12.4%. Since
(4.9%). According to Diagnostic and Statistical Manual of age group included in present study is 5 to 7 y, Level I profile is
Mental Disorders (DSM-5), learning disability is two to three used and if any child does not perform adequately, he/she is con-
times more prevalent in boys than in girls [1]. In an article pub- sidered to have specific learning ‘difficulty’, not disability.
lished in JAMA that includes four large epidemiological studies Neuronal circuitry is constantly reconstructed in response to ex-
on sex differences in SLD with almost 10,000 participants, it is perience. Hence effective early intervention can potentially bring
clearly evident that SLD is substantially more common in boys in compensatory mechanisms to bridge functional gaps [27].
[24]. A genetic research on X-chromosome has unravelled nine During the course of study, authors observed that the
new genes, which because of their location on X-chromosome, awareness of teachers on SLD was limited. Kamala et al. con-
are known to affect predominantly males [25]. Also physiologi- ducted a study among teachers in Puducherry and found that
cal differences between males and females like developmental their understanding on SLD is sparse [28]. Padhy et al. also
lag in childhood, biochemical (boys are resilient to proteins), and reported the same [29].
neonatal differences (hormonal milieu – more exposure to andro- Strengths of present study are use of standardised screening
gen in boys) could play a role [26]. and assessment tools. Not many studies have been conducted
Similarly, students from government schools (12%) were in 5–7 y age children to identify those ‘at risk’ and this is first
more at risk compared to private school students (2.2%) and such study in the region.
there was statistical significance. Lack of adequate training, The use of NIMHANS index in English could have led to
perhaps due to late admission age, poor parental supervision overestimation of prevalence in government schools. Also
and involvement could be contributing factors. clustering of schools in one region is a limiting factor in
Regarding socio-economic status, 8.3% children from low- generalising the results to whole of Puducherry. The associa-
er socio-economic status were at risk while only 1.6% from tion of other psycho-behavioral conditions were not looked
high SES were at risk, yet there was no statistical significance. for in the participants. Those identified ‘at risk’ need reassess-
Similar finding was noted by Padhy et al. [2]. Karande and ment at 8 y since few maybe ‘normal late developers’.
98 Indian J Pediatr (February 2020) 87(2):94–98