SPECIFIC

LEARNING
DISABILITY
Presenter : Shubha A
Chaired by: Mrs. Merlin A
Contributions

 DSM V :SPEED,COMPUTATIONAL SUBTYPES

 DESCREPANCY-1.5SD ALONG WITH 6MONTHS OF INTERVENTION
 INFO PROCESSING MODEL-VISUAL,PHONETICS
 COMORBIDITIES-ADHD-OMISSION ERROR
 Externalized symptoms as age progress-difficulties in coping skills
 Effort-failure-accept failure-decreased motivation-reduced self esteem-behavioral problems
 Assessment for screening-
 Diagnostic assessments
 Assessments for intervention
 3dimensions of child’s need-
 1.whether visual learner or learning by hearing
 2.Mode of thinking
 3.information processing-traditional –sequential learner and global
 Students behavior-attention seeker/power seeker- developmental approach
corrective approach
remedial approach-psychological model,social
 Major intervention is to Family- good support is must
 School systems
 DSM V not using dyslexia as specific entity
 Multisensory approach
 Maternal risk factors-modifiable RF
 RD-speed and comprehension,
 Dyslexia- developmental &acquired
 ICSE &CBSC-facilities for Child with SLD
 Train teachers
 Skipped milestone
 language-trouble in 2nd &3rd language
 Assessments does not fit for native language
 Giving actual remedial therapy
 & liaison with school
 Role of culture- language itself
 Difference between western and eastern countries??
 In what language we assess-
CONTENTS !!!
 Definition
 History
 DSM V/S ICD
 Sub types
 Assessment
 Intervention
 Challenges
 Definition
 IDEA(Individuals with Disabilities Education
Improvement Act),2006 defines
Specific Learning disability is defined as a disorder
in one or more of the basic psychological processes
involved in understanding or using language,
spoken or written, which may manifest itself in an
imperfect ability to listen, think, speak, read, write,
spell or do mathematical calculations.
 Includes-perceptual disabilities, brain injury,
minimal brain dysfunction, dyslexia and
developmental aphasia.
 Does not include learning problems that are
primarily the result of visual, hearing or motor
disabilities, of mental retardation, of emotional
disturbance, or of environmental, cultural or
economic disadvantage.
Epidemiology
 Lifetime prevalence of SLD- 9.7%
 Reading disorder being most common accounting
for 90% of LD ; boys>girls; ratio of 3-4:1
 Mathematics disorder: 1-2% in the general school-
age population with equal incidence in boys & girls
 Disorders of written expression: 6% of school-aged
children; more common in boys than girls (ratio of
2:1)
 Highest rates in languages with deepest orthographies
Scenario In India
 In India, around 13 to 14 per cent of all school children suffer
from learning disorders. ( 
http://www.merinews.com/article/learning-disability-in-india/15781618.shtml&cp)

 The  prevalence of SLD in Schools is found to be 6.6% with

combined Learning disability being most common 7.5%   Specific Learning
Disabilities and Psychiatric Comorbidities in School Children in South India-IJP ,2017(JAN-FEB)

 Dyslexia (reading disorder) is the most common among the

learning disorders, affecting 80% of all those identified as learning-
disabled.

 The incidence of dyslexia in primary school children in India has

been reported to be 2–18%, dysgraphia 14%, and dyscalculia 5.5%
 LEARNING DISABILITY

DIFFICULTY IN UNDERSTANDING AND PRODUCING WORK

SCHOOL FAILURE

LOSS OF SELF ESTEEM

DECREASED EFFORT

DISCOURAGEMENT

FURTHER SCHOOL FAILURE

DROPOUT

UNEMPLOYMENT/WAYWARDNESS/CRIME
 history
 “We were never born to read.”
 Oral language skills - possessed by humans for 100,000 years; reading was
invented only a few thousand years ago.
Neuroplasticity of the brain makes this possible!
 1896- Pringle Morgan provided the first medical description of an
unexpected difficulty in reading relative to other abilities

 1920s, the neurologist Samuel Orton - neurological basis for the disorder-
delayed development of specialization of the left hemisphere for language

 Minimal brain dysfunction (1966)-Peter Clements

 Learning disabilities (1963)-Samuel Kirk

 first DSM III- “Developmental Reading Disorder”)under the general
category of “Academic Skills Disorder”
 First came in DSM-III-R ‘developmental expressive writing disorder’
 DSM-III ‘developmental arithmetic disorder
 DSM-IV-TR-Reading Disorder
 DSM IV-TR: -disorder of written expression
A. Writing skills assessed by standardized tests substantially below
those expected for the person’s chronological age, measured
intelligence and age-appropriate education.
B. Disturbance interferes with academic achievement or activities of
daily living that require composition of written texts.
C. If sensory deficit is present, the difficulties in writing are in excess of
DSM-IV ICD 10

Reading Disorder 1.Specific Reading Disorder

(No problems in arithmetic permitted )

Mathematics Disorder 2.Specific Spelling Disorder

Written Expression Disorder 3.Specific Disorder of Arithmetic

skills
Not otherwise specified (NOS) 4.Mixed disorder of Scholastic skills
5.Other developmental disorders of
scholastic skills
6.developmental disorder of
scholastic
skills, unspecified
 SUMMARY of DSM-5 changes to SLD

1.Single overarching category (SLD)

With Specifiers for current manifestations
2.Elimination of IQ-achievement discrepancy criterion.
Replaced with 4 criteria:
1.Persistence of symptoms for at least 6 months despite focused
intervention
2.Low academic achievement causing significant impairment
3.Age at onset in school-age years (may manifest fully later)
4.Not attributable to Intellectual Disorder, uncorrected visual or
auditory acuity, other mental or neurological disorders,
psychosocial adversity, lack of proficiency in the language of
academic instruction, or inadequate instruction
3.Severity Rating
Subtypes
1. Reading disorder
2. Mathematics disorder
3. Disorder of written expression
4. Learning disorder not otherwise specified (NOS)
Definition of few key terms
 Phoneme- Smallest sound units in a word
 Phonemic awareness - An explicit awareness that there
are discrete speech sounds (phonemes) in speech.
 Phonological coding- Translating the letters or spelling
patterns of a written word into speech patterns to
identify the word and gain access to its meaning
 Orthography- The representation of the sounds of a
language by written or printed symbols.
 READING DISORDER
 Dyslexia’- ‘dys’ (impaired) + ‘lexicos’ (word)
 Neurobiological in origin.
 Characterized by difficulties with word recognition, poor
spelling and decoding abilities
 Deficit in the phonological component of language that is
often unexpected in relation to other cognitive abilities and the
provision of effective classroom instruction (Lyon et al, 2003)
 Difficulty in naming the letters, mapping the letter–sound
correspondence, and holding the sequence of component
letters and sounds in short-term memory while reading the
whole word.
 Aetiology
Cybernetics/information processing model of
learning:
Learning is a process comprising:-
1. Input (visual and auditory perception, encoding)
2. Integration (sequencing, organization, abstraction)
3. Storage/ memory (recent)
4. Output (language and motor skills)
 Neurological Substrate

 Three systems in the left side of the brain are

Involved in basic word reading:
(1) anterior system in the left inferior frontal region-activates during
phoneme production
(2) left parieto-temporal system that is critical for analyzing the
written word in terms of transforming the orthography into the
underlying linguistic structures
(3) left occipito-temporal system that activates during automatic word
recognition and has been termed the “visual word-form area.”
 Individuals with RD demonstrate a relative underactivation left

temporo-parietal, left occipito-temporal; increased activation in the

right temporal and tempoparietal regions and inferior frontal gyrus.
Cognitive Factors
1. phonological deficit hypothesis (and its
extensionto double-deficit and triple-deficit
hypotheses),
2. visual/magnocellularhypothesis, and
3. cerebellar or general sensorimotor dysfunction
hypotheses.
 Phonological Theory
 most widely accepted

 core difficulty in RD is a specific deficit in the

representation, storage, and/or retrieval of speech sounds

 This phonological impairment hinders the learning of

grapheme–phoneme correspondences
 postulates a straightforward link between an underlying

cognitive deficit and the behavioural problem to be

explained.
Visual/Magnocellular Theory
Proposed visual problems include unstable binocular
fixations and poor visual tracking, abnormalities in
perception of visual motion and poor contrast
sensitivity; underlying biological mechanism-
disruption of the magnocellular pathway
Rapid Auditory Processing Theory
Individuals with RD perform poorly on auditory
tasks and exhibit abnormal neurophysiological
responses to various auditory stimuli
 Cerebellar Theory
 The cerebellum plays a critical role in specific timing
required for some aspects of speech perception (e.g.,
distinguishing between the medial sounds in the
words “rapid” and “rabid”).
 A weak capacity to automatize would impair learning
and fluency in grapheme–phoneme matching.
 Anatomical, metabolic, and activation differences in
the cerebellum of individuals with RD
 Genetic factors
 Family, twin, and molecular genetic studies - RD is
highly familial and heritable
 Up to 50% of children of parents with RD, 50% of
siblings of a child with RD may have the disorder
 Genetic factors account for 69- 87 % of individual
differences on phoneme awareness, word
recognition, phonological decoding, and orthographic
coding
 Molecular genetic studies of RD have reported
several susceptibility loci on chromosomes 1p, 2p,
3p, 6p, 11p, 15q, 18q.
According to ICD
 ICD- 10: The individual's reading performance
should be significantly below the level expected on
the basis of age, general intelligence, and school
placement.

 Performance is best assessed by means of an

individually administered, standardized test of
reading accuracy and comprehension.
 Commonly Used Standardized Tests of Reading and
Reading-Related Skills

Reading Component Name of Test

Basic reading skills (e.g., phonological Comprehensive Test of Phonological

awareness, phonological coding, working Processing (CTOPP); standardized for ages 5
memory, rapid naming) yrs to young adulthood

Single-word reading accuracy Woodcock Johnson-III

Single-word reading efficiency (e.g., speedy Test of Word Reading Efficiency (TOWRE);
and accurate naming of single words and standardized for ages 5 yrs to young adulthood
pseudowords)

Reading fluency and comprehension (e.g., rate Gray Oral Reading Test; Nelson-Denny
of reading connected text for meaning) Reading Test; Gray Silent Reading Test
Assessments used at our setting
 Dyslexia Screening Test- Junior (DST-J)- Indian Edition
 NIMHANS SLD Battery
 Visual Perception Test (Keith and Beery)
 Visual-motor Integration Test (Beery)
 Digit Memory Test
 Diagnostic test for Learning Disorder (DTLD)
 Psycho-linguistic rating scale
 Wide Range Achievement-3 (WRAT-3)
 Kirklee’s Reading Assessment Schedule
Co morbidities

 ADHD
 Conduct disorder
 Anxiety and Depression
 Other learning disorders and developmental
disorders
Differential diagnosis
 Mental retardation,
 developmental coordination disorder,
 communication disorders,
 ADHD,
 conduct disorder and
 hearing or visual problems.
Course and prognosis
 diagnosis of RD is not usually made before the
child is about 6 or 7 years old
 RD does not remit with age or time in the absence
of effective intervention
 Course complicated by associated co-morbidities
Mathematics Disorder
• 1975 (WHO)&1978(ICD-9) - specific arithmetical
retardation
• 1980(DSM-III)- developmental arithmetic disorder.
 refer to impairment in the development of arithmetic
skills, including but not restricted to computational
procedures used to solve arithmetic problems and the
representation and retrieval of basic arithmetic facts
from long-term memory
 Four areas of difficulty have been suggested:
1. problems with number (magnitude)
representation;
2. counting problems;
3. number–fact storage problems,
4. Working memory/executive impairments.
 DSM-IV-TR permits co occurrence of language
related disorders but ICD-10 excludes the same
 DSM5- subsumed under SLD, with a specifier.
A four-step developmental model has been proposed to better account for

the heterogeneity of mathematics disorder.

 This model acknowledges the primacy of “number
sense,” but argues that the basic quantitative
capacities develop further through formal education
and require additional cognitive
capacities,including working memory and
linguistic symbolization of number.
Presentation
 in kindergarten and early elementary school the
children present with problems in number concepts
and counting skills
 In older children (i.e., third grade and above),
major impairments are evident in rapid retrieval of
number facts (e.g., 6 × 7) and in completing the
arithmetic procedures necessary to solve more
complex arithmetic problems
Comorbidities
 Most frequently encountered cognitive problem in other
learning disorders(e.g., specific language impairments,
reading disorder),
 Genetic deficits (e.g., velocardiofacial syndrome, fragile
X syndrome, Down syndrome, Williams’ syndrome,
Gerstmann’s syndrome),
 Neurological disorders (e.g., epilepsy),
 Psychiatric disorders (e.g., ADHD,bipolar disorder)
 many of these disorders are associated with abnormalities
in the parietal lobes and dorso-lateral prefrontal cortex.
Disorders of written expression
 French neurologist A. Pitres in 1884.
 Written language is the graphomotor execution of
sequential symbols to convey thoughts and
information
 characterized by poor writing skills that are
significantly below what is normal considering the
child’s age, intelligence, and education, and which
cause problems with the child’s academic success
or other important areas of life.
 Aetiology
Neuropsychological factors
 Three critical components of writing- transcription, text generation,
and executive function- to be supported by short-term memory,
working memory, and long-term memory.
 Orthographic coding (the ability to encode visual information in
printed words rapidly, accurately, and automatically) has a more
direct effect on handwriting than does fine finger control.

Perinatal Factors
 Extreme prematurity (i.e., <28 weeks' gestation or birth weight of
<1,000 g) has been associated with extremely poor spelling in the
primary grades, as well as with poor reading and mathematics.
Genetic Factors

 Family studies reveal increased rates of spelling-disabled sibs in

families with a spelling-disabled proband.

 Molecular genetic studies provide preliminary evidence for linkage of

spelling disability to chromosome 15 and for orthographic skills to be
linked to chromosome 6.

 Four candidate genes are reported to co-segregate with deficits in

written language (DYX1C1 on 15q, KIAA0319 and DCDC2 on 6p,
and ROBO1 on 3q).
Presentation
 Problems with written work
 Excessive technical problems of punctuation,

capitalization, grammar and sentence structure

 Frequent use of nonpermissible letter strings

 Confusion of similar letters or sounds

 Poor organization of written work

 Illegible hand writing

 Spelling problems

 Failure to edit work

Comorbidities
 ADHD is the most commonly co-occurring psychiatric
disorder.
 A clinical study found that a disorder of written expression
was present in 65 percent of children with ADHD.
 Deficits in social skills, self-esteem, and peer relationship
problems may be present.
 Other developmental disorder like reading disorder,
mathematics disorder, motor skills disorder(developmental
coordination disorder), communication disorders (e.g.,
mixed receptive-expressive disorder), and mental
retardation.
Test Components of Written Age range
Language Assessed

Wechsler Individual Spelling, written expression 5–19 yrs

Achievement test (WIAT-II)

Test of Written Language 1. Elicited writing, including 7.5–17.9 yrs

(TOWL; 3rd edition) vocabulary, spelling,
capitalization and
punctuation, logical
sentences, sentence
combining
2. Spontaneous writing

Test of Early Written Basic, global, and contextual 3–11 yrs

Language (TEWL; 2nd edn) writing
Test Components of Written Age range
Language Assessed

Test of Written Spelling Spelling of phonetically 6–18 yrs

(TOWS; 4th edition) regular and nonregular words

Test of Written Expression ‘’ 6.5–14.9 yrs

(TOWE)

Woodcock-Johnson Dictation, proofing, writing 5 yrs–adulthood

Psychoeducational Battery fluency, writing samples

Oral and Written Language ‘’ 5–21.9 yrs

Scales (OWLS)
Differential diagnoses

Mental retardation,
impaired fine motor coordination,
impaired vision or hearing,
communication disorders, and
ADHD.
Non-Verbal Learning Disability (NVD or
NVLD)...recently found SLD!!!

 It is a disorder which is usually characterized by a

significant discrepancy between higher verbal skills
and weaker motor, visual-spatial and social skills.
 Nonverbal learning disabilities often go
undiagnosed because reading ability tends to be
regarded as the chief indicator of academic well-
being by most public school systems
PRESENTATION:-

 Has trouble recognizing nonverbal cues such as facial expression or

body language
 Shows poor psycho-motor coordination; clumsy; seems to be
constantly “getting in the way,” bumping into people and objects
 Using fine motor skills a challenge: tying shoes, writing, using
scissors
 Needs to verbally label everything that happens to comprehend
circumstances, spatial orientation, directional concepts and
coordination; often lost or tardy
 Has difficulty coping with changes in routing and transitions
 Has difficulty generalizing previously learned information
 Has difficulty following multi-step instructions
 make very literal translations
 Asks too many questions, may be repetitive and inappropriately
interrupt the flow of a lesson
Intervention

Student level
 Remedial education-The cornerstone of treatment.

 Should begin early (the central nervous system’s higher

plasticity in early years)

 Accommodations- Alterations in the way tasks are presented

 Assignments same as other students

 The Individuals with Disabilities Education Act states that a

child's IEP (Individualized Education Program) team -which

both parent and child are a part of the program - decide which
accommodations are appropriate
 Examples of accomodation:
 Presentation
Provide on audio tape, provide in large print, reduce number
of items per page or line, provide a designated reader, present
instructions orally.

 Response
Allow for verbal responses, for answers to be dictated to a
scribe, allow the use of a tape recorder to capture responses,
permit responses to be given via computer, permit answers to
be recorded directly into test booklet.
 Timing
Allow frequent breaks, extend allotted time for a test

 Setting
Provide preferential seating, provide special lighting or acoustics,
provide a space with minimal distractions, administer a test in small
group setting, in private room or alternative test site

 Test Scheduling
Administer a test in several timed sessions or over several days, allow
subtests to be taken in a different order, administer a test at a specific
time of day
Technological aids for students
 Help with reading- electronic file, scanners

 Help with writing- predictive software,

spellcheckers and grammar checkers

Teacher level
 Additional sessions: to help understand the topic,

organize ideas, revise study skills

 Reading: picture dictionary, flash cards, picture
cards with missing letters
 Comprehension activities: visual image of story,
read a passage and give appropriate title
 Instructional games in reading: word bingo
 Reading programmes: DISTAR, Edmark reading
programme
 Maths: maths games, candy counter
 Writing programmes: ‘hand writing fresh start’
At the State/ Board level:

 Being an invisible handicap, there is no uniform national guideline in

India, for diagnosis, assessment of severity, and certification of SLD.

 SLD in not recognised in the PWD Act 1995.

 The only facility that these children can avail of is the provisions for
examinations conducted by the various boards of examinations. There
is no uniformity in these either.

 Benefits- (i) Extra time to answer examination paper (ii) use of

calculator (iii) using Clarke’s table (iv) appointment of scribe to read
the question paper or answer the paper
 SLD has been now included in the Rights of
Persons with Disabilities Bill, 2014 .
Challenges :-
 Stigma and negative connotation of inferior intellectual
ability and poor attitude (laziness, oppositionality)

 Critical differences in reading and the manifestation of

RD in different languages
 the issue of male vulnerability to reading disorder (and
other neuro developmental disorders) is controversial

 Resources for assessment and intervention!

References
 Kaplan and Saddock- Comprehensive Textbook of
Psychiatry- 10th Edn.
 Rutters child psychiatry 6th edn
THANK YOU