REVIEW OF IPS –CPG GUIDELINES ON

ASSESMENT AND MANAGEMENT OF

IDD AND SLD

Presented by : Dr. Skarma Tsultim

Chaired by : Dr. Moushumi P. Mukherjee
 Content
IDD SLD
• Introduction - Introduction
• Etiology - ICD (SDDSS)
• Comorbidities - DSM-5 (SLD)
• Assessment - Assessment
• Management - Diagnosis
• - Management
Intellectual Developmental
Disorder(IDD)
Introduction
 Also called as Intellectual disability (Dsm-5) or Mental retardation (ICD-10)

 However Rosa’s law in the US (2010) and Rights of Persons with Disability Act,
India (2016) has replaced the term Mental Retardation as ID and IDD
respectively

 IDD (Salvador- Carulla et al,2011) term in ICD-11

 IDD as the name suggests is a disorder which onsets during the developmental
period of an individual and is characterized with significant impairment in
Intellectual functioning and Adaptive behavior
Introduction
 It has a global prevalence rate of 2.5%

 However Indian studies shows a wide range of point prevalence ranging from 1/1000 to
32/1000. (depending on case definitions, methodology and population selected)

 Male > female ( 30% more in mild IDD)

 Global developmental delay (GDD) is a diagnosis used when it is difficult to diagnose

as IDD esp. in younger age group (3 months to 5 years) and also in individual who are
unable to undergo systematic assessment of intellectual functioning
Introduction
 GDD as per ( shevel et al ,2008) ,significant delay in 2 or more of the following
developmental domains
o Gross/ fine motor
o Speech/language
o Social/personal
o Cognition
o Activities of daily living

 But not all cases diagnosed as GDD progress to have ID

ETIOLOGY OF IDD
 The causes of IDD is heterogenous and is broadly classified under genetic and
environmental causes

 Majority of cases however have a genetic cause (2/3rd)

 But non genetic causes ID are more static and amenable for training and also are
preventable in subsequent pregnancies (eg Diet, drug,
substance)

 Diagnosis of genetic etiology is very important for proper management and also for
genetic counselling in case of prenatal diagnosis or plan for subsequent pregnancy
CO-MORBIDITES
 Epilepsy is a common comorbidity with a prevalence of 15-30% and
around 50% in severe IDD

Medical co-morbidities Behavioral problems

- Spasticity, dystonia , ataxia , V.I , H.I
- Congenital heart disease , congenital renal
malformations,
- Cleft lip, cleft palate, congenital talipes
equinovarus,
- Failure to thrive with vitamins and mineral
deficiencies ,
- Recurrent infections, feeding disorders and short
stature
-Self injurious behavior in Lesch-nyhan syndrome,
-Skin picking and OCD in Prader Wili syndrome,
-Autistic traits and hyperactivity in Fragile X
syndrome,
-Self hugging stereotypy and trichotillomania
in smith-magenis syndrome,
-Schizophrenia like disorders in 22q11 deletion
syndrome
CO-MORBIDITES
 The associated comorbidity needs to be identified and addressed as it will act as
a barrier against training and making developmental gains

 The most common co-occurring mental and neurodevelopmental disorders are

 ADHD; Depressive and Bipolar disorders; Anxiety disorders

 Autism spectrum disorder; stereotypic movement disorder (with or without

self-injurious behavior)

Impulse-control disorders; and Major neurocognitive disorder

CO-MORBIDITES
 People with IDD are at 3-5 times greater risk of psychiatric disorder compared to
general population

 IDD itself can be a a cause , while social discrimination and deprivation can also
influence

 In most patients with IDD symptom presentation of a comorbid psychiatric illness

will be atypical and often ignored as spectrum of ID.

 Therefore Clinicians have to be on the look out for a possibility of comorbidity.

ASSESSMENT AND EVALUATION
 The Goals are
 To identify the condition using criteria

 To identify and treat etiological and risk factors

 To identify the needs due to the disability and design plan to reduce its impact

 Use best intervention methods to meet the needs

 To evaluate for effectiveness of intervention

 ASSESSMENT
Diagnosing IDD and Comorbidities:
a) History taking
 It is similar to the one we follow in OPD but we should be able to establish deficits in
intellectual functioning and adaptive behavior during childhood in the HOPI

 Informants should include parents/caregivers who know birth and developmental

history

 History should include detailed perinatal, natal and postnatal history

 ASSESSMENT
Developmental history should have in detail , attainment of
 Motor milestones
 Language and communication
 Self help skills
 Socio emotional skills
 Cognition
 Hobbies
 ASSESSMENT
b) Physical examination-
Anthropometry Height ( length in infants) ,sitting height, arm circumference,
Upper segment: lower segment, weight,head circumference, chest
circumference, abdominal circumference, intercanthal and
interpupillary distance, pam and foot length

Dysmorphology exam It consists of looking for minor physical anomalies(MPA’s), which

suggests etiological diagnosis( genetic disorders)

General physical exam Respiratory, CVS, CNS, abdominal exam. To rule out multi organ
involvement and co morbid medical conditions
 ASSESSMENT
 Presence of 4 or more MPA’s should alert towards probable genetic cause
 ASSESSMENT
c) Behavioral observation :
-It involves the use of M/S/E And cognitive function assessment

GAAB: Oddities in behavior, attention span, receptive and expressive speech, social
and interpersonal abilities.

Cognitive assessment : general fund of knowledge, generic concepts, abstract thinking,

reasoning, problem solving (not strictly dependent on academic learning)
 ASSESSMENT
d) Intellectual functioning and adaptive behavior :
-To confirm the clinical diagnosis and identify the severity of ID

ICD- 10 DSM -5

COMPONENTS ARE -COMPONENTS ARE

COGNITION,LANGUAGE,MOTOR AND SOCIAL REASONING,PROBLEM SOLVING,PLANNING,
SKILLS ABSTRACT THINKING,JUDGEMENT,ACADEMIC
LEARNING AND LEARNING FROM
EXPERIENCE:
SEVERITY :ON BASIS OF STANDARDIZED TOOL SCORE <75 = ID
MILD : 50- 69
MODERATE :35-49 SVERITY BASED ON ADAPTIVE FUNCTIONING
SEVERE : 20-34 BASED ON 3 DOMAINS
PROFOUND: < 40 CONCEPTUAL
SOCIAL
PRACTICAL
ASSESSMENT
RPD ACT 2016
- IQ < 70 FOR ID

- VINELAND SOCIAL MATURITY SCALE : TO ASSESS SEVERITY

• Only standardized measure available in india at present

• Yields a social quotient (SQ) and Covers profile of 8 domains of adaptive behavior
1. SELF HELP GENERAL
2. SELFHELP EATING
3. SELF HELP DRESSING
4. SELF HELP DIRECTION
5. COMMUNICATION
6. OCCUPATION
7. LOCOMOTION
8. SOCIALIZATION
 ASSESSMENT
 It consists of total of 89 items

-PROFOUND DISABILITY = < 20 (100%)

-SVERE DISABILITY = 21- 35 (90%)
-MODERATE= 36-54 (75%)
-MILD = 55- 69 (50%)
-BORDERLINE = 7- 84 (25%)

-When IQ and SQ indicate different severity decision is taken in favour of SQ

-As it indicates the degree to which the individual is able to meet culture appropriate demands of daily life
ASSESSMENT
e) Diagnosis of comorbid psychiatric disorder
• The clinician has to assess any decline in overall functioning during each visit

• If decline is progressive , a comorbid psychiatric disorder is to be suspected

• Life charts can be used

• School reports can serve as a valuable source of information

 ASSESSMENT
• Behavioral observation , starts when the child enters the room

• Play room observations and multiple baseline observations for

Functional analysis can be taken

• Setting of the interview should be child friendly with toys, picture books and art&
craft materials

• After building rapport with the child verbal interview can be conducted
ASSESSMENT
 From the interview we should note

1. Behavior suggesting sensory motor impairment if any

2. Response to interview situation: excited , shy, tense, guarded, defiant

3. Alertness

4. Attachment to parent and response to separation

5. Sociability: approachability, ETEC, reciprocal interactions

6. Motor activity level

7. Impulse control: snatching, falling, temper tantrums, aggressive acts

8. Attention concentration: task completion, distractibility

ASSESSMENT
10. Speech, language and communication: verbal/ non verbal

comprehensibility and expression, vocabulary, flow

11. Mood : crying irritable ,cheerful

12. Play behavior : type of activity, duration , themes

13. Parent-child interactions : quality of engagement, communication

pattern, degree and quality of control, response to good and bad

behavior
 ASSESSMENT
 Standardized instruments can be used but only to complement the clinical
findings. Some of them are:

 Psychiatric assessment schedule for adults with development

disability

 Reiss screen for maladaptive behavior

 Psychopathology inventory for M. R adults

 Developmental behavior checklist

ASSESSMENT
f) Laboratory investigations :
• Since most of children with IDD will have some behavioral issues and it might not
be possible to examine them completely some MPA’s can be missed
• Malformations such as ASD, Single kidney, holoprosencephaly and mild hearing or
visual impairment can be missed in OPD setting
• Therefore some investigations might be necessary to identify the etiology of IDD
and in turn to treat.
• Which investigations are necessary and why has to be clearly explained to the
family
ASSESSMENT
 ASSESSMENT
G) Psycho social assessments:
i. Assessment of family needs and functioning
 Parents and families are the backbone of a person having ID. Therefore their
understanding of the condition , support they receive, and stress and coping
mechanism used them are important moderators of any intervention meted.
 Some of the tools to evaluate the support system are
 Disability impact scale
 Family support scale
 Family efficacy scale
 Family need schedule
 ASSESSMENT
H) Psychoeducational assessments:
Depending on the severity a child with IDD can either go to mainstream or special
school
To assess what school and which grade he/she’d be admitted some tools can be used,
namely
 Grade level assessment device (NIMH)
 Functional assessment checklist for programming

But younger children when they should be sent to school, there is no standardized tool
available and child needs clinical assessment for it
 MANAGEMENT

FORMULATING TREATMENT PLAN
 It is planned so as to address the 5 major dimensions

I. Level or severity of ID
II. Etiology / syndrome
III. Comorbid medical illness
IV. Comorbid psychiatric illness
V. Family and psychosocial factors
MANAGEMENT
 Based on these dimensions biological, psychological and social intervention is
decided

Setting for intervention

- Unless otherwise, OP setting is considered as best for management
as they can have maximum opportunity for learning and
development in community
MANAGEMENT
 For medical comorbidities
 Many of associated medical comorbidities can be treated and should be addressed at
the earliest

 Like A.E.D’s for associated seizure disorder

 Anti spastic medications(baclofen , dantrolene , diazepam) for spasticity

 Hearing aids/ cochlear implants for children with H.I

MANAGEMENT
 Some of other medical interventions
 MANAGEMENT
 Genetic counselling:
 As Discussed earlier around 2/3rd of the IDD have genetic etiologies

 Therefore genetic counselling is mandatory

 It includes educating the parents of a child with ID

• the risk of recurrence in subsequent pregnancy

• If a prenatal diagnosis is possible

• It also helps to remove guilt and improves IP relation in families

 MANAGEMENT
FOR COMORBID PSYCHIATRIC ILLNESS AND BEHAVIORAL
DISTURBANCES :
• Around 20 -80-% of people with IDD have behavioral problems

• Hyperactivity, temper tantrums, odd behaviors and in some cases aggression

• It leads to stigma, segregation not only to the child but also to the parents, thus
increasing care giver’s burden and which can in turn lead to negative expressed
emotions and a vicious cycle can start

• Thus first step is Behavior analysis (ABC)

 MANAGEMENT
 The principle of behavioral management is to facilitate positive behaviors to replace
negative behavior

 It can be implemented through 3 levels

a. Restructuring the environment : to control antecedents and provide

environment for positive learning

b. Differential reinforcement : to strengthen the adaptive behavior by providing

opportunity for reinforcement for adaptive behavior

c. Controlling inappropriate reinforcement of problematic behavior

MANAGEMENT
 As discussed before , a clinician has to be on a look out for masking or diagnostic
overshadowing

 Psychiatric comorbidity is not only difficult to diagnose but also difficult to treat than
the general population

 Approach should be multipronged as pharmacological as well as psychosocial

intervention should be tried

 Pediatric dosing schedule and guidelines should be followed

MANAGEMENT
Pharmacological Rx
 MANAGEMENT
 Non pharmacological interventions
1) Child-centric intervention
a) Lifespan approach :
- As per this approach skill training should be as per developmental stage (age)
 Up to 3 years = focus on sensory motor skills, socio-communication skills ,basic
self help skills and concept building.
 3-6 years = Teaching school readiness skills and culturally appropriate adaptive
behaviors
 6- 18years = Focus on strengthening academic and independent personal skills that
will help in future employment and adult independent living
 MANAGEMENT
b) Functional approach :
 It focuses on teaching tasks that will help him to function well in everyday living
 Irrespective of age and social background everyone first needs self care skills(toilet
control , bathing, eating, dressing and grooming)
 Sight words (EXIT,DANGER,OWN NAME)
 Motor skills (eg. hand eye coordination)
 Receptive and expressive language ability
 Social skill and concept together
 Later functional academics tailored to help him secure job and independent living
 Management
 Early intervention:
• It can start at prenatal period in terms of identifying high risk pregnancies and
providing appropriate health care or helping family overcome psychosocial adversity

• Post natal -

 Accurate diagnosis of ID and other comorbidities

 Activities to facilitate sensory motor integration, speech language development,

socio-emotional development

 Healthy bonding between mother and child

 Management
 Material for intervention should be easily available and culturally appropriate

 Depending on stage of development, referral can be made

 Early age – RBSK And Anganwadi centers(ICDS)

 School age – Sarva shiksha abhiyan, National institute of open schooling

 College – vocational training under National Trust Act

Management
2) Family-centered intervention :
• Families should be educated about the condition , needs , management and
comorbidities in simple language

• Sources of literature about the specific condition should be shared

• Guidance for finding right resources for health care, therapy , education, vocational
and occupational needs

• They should be made aware of social provisions and Disability certificate

Management
• Individual counselling, Group counselling, parent training programs, self help
groups can be introduced to family
• Family support programs should be individualized
• Family and caregivers should be routinely screened for stress related disorders
as they are at risk for developing depression and anxiety
SPECIFIC LEARNING
DISORDER
(SLD)
Introduction
 SLD is one of the most common neurodevelopmental disorders affecting 3%–10% of
children

 As per Sahoo et al., 2015, prevalence of LD ranges from 2% to 10%.

 The prevalence of learning disorders in India is 5%–17% of the children.

 Male : female for LD is 2.3:1

 Kirk in 1960’s defined LD as “an unexpected difficulty in learning one or more of one
instrumental school abilities.”
Introduction
 He further stated that , it affected language and academic performance of people of all
ages which is caused by emotional disturbance, behavioral disturbance or cerebral
dysfunction

 Bateman mentioned that those with LD have a significant discrepancy between their
estimated intellectual potential and actual level of performance with or without
neurological dysfunction which is not secondary to MR, educational or cultural
deprivation, severe emotional disturbance, or sensory loss
As per ICD -10 (F 81) SDDSS
 They are disturbance in normal pattern of skill acquisition not because of lack of
opportunity to learn nor due to any acquired brain trauma or disease
 But arises from abnormalities in cognitive processing that derive from biological
dysfunction
 There should be clinically significant degree of impairment in specified scholastic
skill.
 Severity can be judged by scholastic terms or developmental precursors (scholastic
difficulties were preceded by developmental delays or deviance, most often in
speech or language in preschool years) or qualitative abnormalities(not part of
normal development)
 SDDSS

 Response– scholastic difficulties do not rapidly and readily remit with increased
help at home/school
 Impairment must be specific– not solely explained by mental retardation/lesser
impairments general intelligence
 Impairment must be developmental– early years of schooling and not acquired later
in the educational process.
 Sub types of SDDSS
1. SPECIFIC READING DISORDER (F 81.0)
• Specific and significant impairment in the development of reading skills which
are not due to mental age, visual acuity problems or inadequate schooling

• Reading performance should be significantly below the level expected of age,

general intelligence and school placement.

• Performance is best assessed by means of an individually administered

standardized test of reading accuracy and reading comprehension
 Sub types of SDDSS
• Early stages: Difficulty in reciting the alphabets, in giving the correct names of letters,
in giving the simple rhymes for words and in analysing or categorizing (despite normal
auditory acuity)
• Later stages: Errors in oral reading skills ,Omissions, substitutions, distortions, or
additions of words or parts of words
• Slow reading rate
• False starts, long hesitations or “loss of place” in text and inaccurate phrasing
• Reversals of words in sentences or of letters within words.
 Sub types of SDDSS
 Deficits in reading comprehension
• Inability to recall facts read
• Inability to draw conclusions from material read
• Use of general knowledge as background information rather than of information
from a story to answer questions about a story read.

2. Specific spelling disorder:

• Characterized by specific and significant impairment in the developmental of
spelling skills in the absence of a history of specific reading disorder which is not
solely accounted for by low mental age, visual acuity problems or inadequate
schooling
 Sub types of SDDSS
3. Specific disorder of arithmetic skills:
• Characterized by specific impairment in arithmetic skills which is not
solely explicable because of general retardation or of grossly
inadequate schooling
• Failure to understand the concepts underlying arithmetical operation
• Lack of understanding of mathematical terms or signs
• Failure to recognize numerical symbols
 Sub types of SDDSS
• Difficulty in properly aligning numbers or in understanding which numbers are
relevant arithmetic/inserting decimal points/symbols during calculations; poor
spatial organization of arithmetical calculations; and inability to learn
multiplication tables satisfactorily

4. Mixed disorder of scholastic skills:

• Characterized ill‑defined/inadequately conceptualised but necessary residual
category of disorders
• in which both arithmetical and reading or spelling skills are significantly
impaired
As per DSM-5 (SLD)
 Difficulties learning and using academic skills, as indicated by the presence of at
least one of the following symptoms that have persisted for at least 6 months,
despite the provision of interventions that target those difficulties
1. Slow/inaccurate/effortful reading
2. Difficulty understanding what has been read
3. Difficulty in spelling
4. Difficulty in written expression
5. Difficulty in mastering number sense, number facts,calculations
6. Difficulty with Math reasoning.
 SLD
 The affected academic skills are substantially and quantifiably below those expected for the
individual’s chronological age (< 1.5 standard deviation below the population mean for age).

 Significant interference with academic / Occupational performance or with activities of daily

living is there

 SLD is confirmed by means of standardized achievement measures and comprehensive

clinical assessment.

 Learning difficulties start at school years. However, they may not manifest till demands in
academics exceed individual capacity ( timed test, excessive workload)
 SLD
 Academic domains and sub skills impairment:
1. With impairment in reading:
• Word reading accuracy
• Reading rate accuracy/fluency
• Reading accuracy

2. With impairment in written expression:

• Spelling accuracy
• Grammar and punctuation accuracy
• Clarity or organization of written expression.
 SLD
3. With impairment in mathematics:
• Number sense
• Memorization of arithmetic facts
• Accurate or fluent calculation
• Accurate Math reasoning.
 SLD
 Mild:
• some difficulties in one or two academic domains; mild enough and can be
compensated or functions well with accommodations/support service especially during
school years

 Moderate:
• Marked difficulties one or more academic skills; unlikely to become proficient without
intensive teaching during school years, accommodations/supportive services at
school/home to complete activities accurately
 SLD
 Severe:
• Severe difficulties, several academic skills; unlikely to become proficient without
ongoing intensive teaching for most of the school years, despite
accommodations/supportive services at school/home may not complete activities
accurately
Assessment
I. Clinical Evaluation :

• Children with SLD are brought either by parents or referred from school
• They are often compared with others who perform well in academics and face
punitive experiences in the home as well as school contexts

 Clinical presentation varies from

complaints of

- Poor academic performance

 ASSESSMENT
 whereas others can present with symptoms secondary to the poor academic
performance which may include

- School refusal, oppositional behaviour, aggression,

 Poor motivation for studies, depressive symptoms,
 Somatic complaints (pain symptoms, fatigue)
 Dissociative symptoms (pseudo seizures, dissociative sensory loss, dissociative
amnesia etc.
ASSESSMENT
ASSESSMENT
II. Psychometric testing :

• Helps in confirmation of diagnosis and in planning the intervention.

• Includes testing for cognitive abilities and testing for academic abilities

IQ assessment :
It can be done using Standardized IQ tests. The tests that can be used include Binet–
Kamat Test, Malin’s Intelligence Scale for Indian Children (MISIC), Wechsler’s
Intelligence Scale for Children‑4th Edition
ASSESSMENT

• MISIC will provide Performance IQ , Verbal subscale IQ and Full‑scale IQ.

• In children with SLD , there is a discrepancy between verbal and performance
IQ’s with the performance IQ usually being higher.
• “ACID‑profile” has been described where children may score low on subtests of
Arithmetic, Coding, Information and Digit‑span
ASSESSMENT
 For assessment of Academic abilities, some of the following tests may be used:

• NIMHANS Index for SLD

• Wide Range Achievement Test
• Test of written language‑4
• Wechsler Individual Achievement Test
• Woodcock‑Johnson III/IV Tests of achievements (WJ‑III)
• Kaufman Test of Educational Achievement
• Peabody Individual Achievement Test‑Revised
• Aston Index Battery
 ASSESSMENT
 Apart from NIMHANS Index for SLD none of the afore-mentioned tests has been
adapted / validated in Indian population

NIMHANS INDEX FOR SLD

• Its the most commonly used battery in the Indian context
• Reliability and validity of this tool has been established
• It includes the tests in two levels
• Level I is for 5–7 year old
• Level II for 8–12 years old
 ASSESSMENT
TESTS IN LEVEL I TESTS IN LEVEL II

1. Visuo‑motor skills (copying of three geometrical figures) 1. Number cancellation

2. Writing of capital letters 2. Reading of English passages
3. Writing of small letters 3. Spelling of English words (including
4. Writing of an alphabet preceding a specified alphabet Schonell’s 15 words list)
5. Writing of an alphabet succeeding the specified alphabet 4. Reading comprehension of English passages
6. Writing of numbers serially 5. Arithmetic subtest
7. Writing of numbers preceding a specified number 6. Bender Gestalt test for visuo‑spatial abilities
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 (both receptive and expressive).
ASSESSMENT
LEVEL I TESTS LEVEL II TESTS

-Assessment of preacademic skills; -Assess areas of attention, reading,

attention, visual and auditory discrimination, spelling,
visual and auditory memory, - perceptuo‑motor, visuo‑motor
-speech, and language, Integration,
-Visuo‑motor and language, -memory, and arithmetic skills
- writing and number skills
ASSESSMENT
DIAGNOSIS
 A child with LD is one who does poorly in academics because of impaired ability in
learning the academic skills of reading, writing, arithmetic, and spelling

 To diagnose SLD, impairment should not be because of ID, subnormal intelligence,

neurological disorders, visual/hearing acuity problems or inadequate schooling, but
due to a specific type of dysfunction in cognitive processing
Diagnosis
 Unlike those with general learning disorder , children with specific learning
difficulties possess average to above average levels of intelligence across many
domains of functioning, but have specific deficits within a narrow range of academic
skills.

 Concept of unexpected academic difficulty is central to the definition of SLD

 Using the Rutter’s multi‑axial diagnosis will provide a better understanding about the
child’s problems and in setting up an effective treatment plan.
 DIAGNOSIS
EARLY IDENTIFICATION OF CHILDREN AT RISK :
 Risk indicators must be checked in any screening evaluation.
 Some of screening tools used in India for early identification are
• Specific Learning Disability–Screening Questionnaire, This can be used in the
school setting by teachers.
• Dyslexia Assessment for Languages of India (DALI)
 - It’s a comprehensive screening and assessment battery for children with or at risk
for dyslexia, between the classes of 1–5 developed by National Brain Research
Centre (NBRC) with support from Department of Science and Technology,
Government of India.
 DIAGNOSIS
DALI has two screening tools:
 Junior Screening Tool for classes (1–2) (5–7 years).
 And middle screening tool for classes (3–5) (8–10 years)
• In addition, there are 8 Assessment Batteries and includes testing in English and
the mother tongue
DIAGNOSIS
MANAGEMENT
 Psychiatrist is often the primary contact person who suspects, assesses, screens for
SLD and evaluates for co‑morbidities and treats them.

 a multi‑disciplinary team (psychologist, special educator ,occupational therapist,

language speech therapist and paediatrician) would be useful in the holistic
evaluation and management of these disorders
MANAGEMENT
a) Management of the core deficits :

i) ACCOMODATION :

 facilitate the student to access the educational material

 This decreases the burden and stress on the child

 Includes larger size pen/pencils, use of grippers, special papers which provide tactile
feedback, use of spell checkers, audio books, and technological devices.
 MANAGEMENT
 Individualizing assessments in terms of time length and allowance for breaks can
be planned

II) MODIFICATION :
 task and academic expectations from child are changed
 Change in the delivery, content or instructional level of subject matter or tests are
implemented
 This could include oral assignments, writing in short, may focus either on content
or spelling, not having to read aloud and extra time, learning lower level of
mathematics or dropping a language
 MANAGEMENT
 REMEDIAL EDUCATION :
- a process to help the child acquire age appropriate skills in all his

foundation areas which are required for attaining knowledge at his

pace and potential

 include direct teaching, learning and time for consolidation

 Repeated revisions is necessary for varying attention

 It should be child centric, strategy taught for learning the content

MANAGEMENT
 the intervention should be intensive 2–3 times a week and either at individual
level or in a small group (1–2)

 Following improvement, 50% children maintain gains for 1–2 years. This is more
so when intervention is early (6–8 years)

 fluency improves rather than comprehension

 Changes in brain occur with remediation and which reflect plasticity of the brain
MANAGEMENT
 Depending on the type and severity of the problem, an individual educational plan
is made for the child

 In early years = developing language skills and basic skills of reading, writing
and mathematics are the area of focus

 In middle school = basic skills + concepts, critical thinking and problem solving

 In secondary school = accommodations and modifications to help the child to

cope become more prominent
MANAGEMENT
SPECIFIC EDUCATIONAL STRATEGIES
1) READING :

- It is problems of decoding (usually referred to as dyslexia)

- phonological awareness needs to be increased

- phonemes, which is the smallest unit of speech, e.g., k in kit, b in bat.

- Phonemic awareness includes ability to hear and manipulate individual phonemes.

 MANAGEMENT
 Isolation, the training is in recognizing the individual sounds in words.(tell me the

first sound in the letter hat)

 Phoneme identity: The ability to distinguish the common sound in differing words
(tell me the sound that is same in pod and pan)

 Phonemic substitution: Replacing one phoneme for another to create a new word
(cat‑mat, bad‑bat)

 Oral segmenting is being able to break the word into different sounds (ban b/a/n)

 Oral blending is joining the sounds to form words (c/a/n is can).

 MANAGEMENT
2) WRITING :
- It is more complex than reading
 May occur independently or co occur with reading disorder
 Eye hand coordination and ability to segment phonemes is important
 Basic motor functioning is enhanced using hand exercises such as working with
clay, beading and finger tapping
 To improve spelling, phonics instruction and teaching of letter writing is used
(following numbered arrow cues, hiding letter and visualizing writing letter)
 MANAGEMENT
• To target higher order skills of writing an essay, which involve planning,
organizing, reviewing and editing skills, practice using concept maps and different
aids and strategies are employed

• Writing clubs and self‑regulated strategy development have shown to be useful

MANAGEMENT
3) MATHEMATICS :
 Educational strategies include practicing number syntax (linking numbers to
related digits; e.g., 1234

 Repeated additions help in internalizing the number line

 Verbalization of arithmetic concepts, procedures and operation is helpful as is

explicit instruction

 Drill and practice also help to remember number facts

MANAGEMENT
MANAGEMENT
Children with poor language skills :
 Many children who are first generation learners or have poor exposure to English
language
- face difficulties in all aspects of academic achievements
- Shouldn’t be misdiagnosed as SLD
- Sometimes however both can occur
 Apart from specific intervention, English enrichment program can be meted
 MANAGEMENT
Mitigating the impact of specific learning disorder
 Psycho educating the family about the condition is must
 Family counselling may also be required to combat the negative attitudes and
behaviour
 Low self‑esteem which is a common finding will require specific intervention

 Protective factors that foster resilience are useful and include self ‑advocacy tools,
identifying strengths, and improving social connections
 MANAGEMENT
CO-MORBIDITY :
o Comorbidity is a rule rather than an exception

o Some may be the presenting illness ( eg [ADHD]/autism spectrum disorder),

o some may be a consequence (depression) and some may be blended with the disorder
(anxiety and behavioural symptoms)

o If ADHD is present requires treatment even before assessing as it interferes with the
results
 MANAGEMENT
o Pharmacotherapy for ADHD has had a varying effect on the reading disability
o CBT and mindfulness meditation is shown to improve the emotional health with the latter
also improving attention
MANAGEMENT
 PREVENTION AND PREDICTION
• Cognitive skills that predict literacy are letter sound knowledge and phoneme awareness

• A well‑trained teacher would be able to identify children who are struggling. This could
be supported with checklists

• The early intervention for at risk children for dyslexia could be phonological skill training

• Besides phonological processes, communication impairment and deficits in naming speed

are predictive of future SLD
 PREVENTION AND PREDICTION
• Language impairments are a risk for reading comprehension difficulties in the
future
• Better outcomes for decoding are seen when parents teach print concepts and for
comprehension when parents share reading with offspring.
LAW AND SLD
 SLD is one of the bench mark disabilities encompassed in the Rights of Persons With
Disability Act, 2016
 access to free education in an appropriate environment (till 18 years of age).(GOVT
INSTITUTE)
 Not less than 5% seats for persons with benchmark disabilities (which includes
SLD)and upper age relaxation of 5 years for admission in institutions of higher
education(GOVT INSTITUTE)
 not <4% of the total number of vacancies in the cadre strength in each group of posts
is meant to be filled with persons with benchmark disabilities of which, 1 percent
each shall be reserved for persons with particular benchmark disabilities and one of
which is SLD.
ROLE OF PSYCHIATRIST IN SCHOOL
1. Enlist the engagement of school by making them empathetic to needs of child,
advocate for child in school

2. Psycho educate the teachers

3. Facilitate screening in school

4. Create agreement with goals acceptable to all stakeholders

5. Mobilizing the school system to help the child and empowering them to do so
ROLE OF PSYCHIATRIST IN SCHOOL

6. Raising awareness about social, emotional, behavioural symptoms associated with

SLD. Training teachers to identify, refer and use classroom management strategies

7. Refer introduce for further resources

8. Certification of the disability

REFERENCES
 ICD-10
 DSM- 5
 Clinical practice guidelines on assessment and management of specific learning disorder , henal rakesh shah et
al .
 Clinical practice guidelines for assessment and management of intellectual disability , M. Thomas kishore,
gautham arunachal et al .
THANK YOU.