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Tilak Municipal Medical College, Sion, Mumbai, Maharastra, India. Abstract. Learning disabilities (LD) is one of the important causes of poor academic ...
Symposium on NeurodeveloPmental Disorders-II

Approach To Learning Disability Madhuri Kulkarni, Sarika Kalantre, Shubhangi Upadhye, Sunil Karande and Sanjeev Ahuja

Division of Neurology, Dept. of Pediatrics, Lokmanya Tilak Municipal GeneralHospital and Lokmanya Tilak Municipal Medical College, Sion, Mumbai, Maharastra, India Abstract. Learning disabilities (LD) is one of the important causes of poor academic performance in school going children. Learning disabilities are developmental disorders that usually manifest during the period of normal education. These disabilities create a significant gap between the true potential and day to day performance of an individual. Dyslexia, dysgraphia and dyscalculia denote the problem related to reading, writing and mathematics. Perinatal problems are certain neurological conditions, known to be associated with LD; however, genetic predisposition seems to be the most probable etiological factors. Evaluation of a child suspected to be having LD consists of medical examination, vision and hearing test analysis of school performance. The psycho-behaviour assessment and education testing are essential in the process of diagnosis. The experienced persons in the field of LD should interpret the results of such tests. With Individualized Remedial Education Plan (IEP) most children leam to cope up with disability and may get integrated in a regular steam. [Indian J Pediatr 2001; 68 (6) : 539-546]

Key words : Learning disabilities; Dyslexia; Remedied education Children who have difficulties in reading and writing fail to show the expected progress in the regular schools. They usually get low grades in school tests and become a source of great anxiety for parents and teachers. Most children having learning disabilities present with poor scholastic performance, especially in the middle secondary school. Besides learning disabilities (LD) there are other causes of school-failure seen in children. Lower levels of intelligence account for a majority of failures. The children with intellectual functioning at "low-normal" ( 80 89) and "borderline" ( 70 - 79) IQ show poor performance due to difficulties in understanding abstract concepts. Children with primary or secondary attention deficits have poor concentration and difficulties in learning. Chronic medical conditions leading to school absenteeism is another important factor causing poor performance in school. Emotionally disturbed children show academic failures. Emotional insecurity may be due to the factors related to home or school environment. A change of school can bring failure in an insecure child due to exposure to a new atmosphere, which at times may be a hostile environment. Also, it should be noted that failure is a common cause of failure. A child who has failed once, develops feelings of inferiority and low self esteem. These factors need to be carefully looked for in a child suspected to be Reprint requests : Dr. Madhuri Kulkarni, Dept. of Pediatrics, LTMG Hospital, Sion, Mumbai-400 002, Maharastra. Indian Joumal of Pediatrics, Volume 68---June, 2001

having LD. Learning disability refers to a d i s o r d e r that interferes with one's ability to store, process or produce information) Lea_mi~ disabilities are seen in children as well as in adults. The impairment may be so subtle that it may go undetected throughout the life. These disabilities create a gap between the true potential and day to day productivity and performance. Definition : National Joint Committee for Learning Disabilities (NJCLD) 1988z Learning disabilities is a generic term that refers to a heterogeneous group of disorders manifested by significant~difficulties in the acquisition and use of skills such as listening, speaking, reading, writing, reasoning or mathematical abilities. These disorders are intrinsic to the individual, are presumed to be due to central nervous system dysfunction and may occur across the life span of the individual. Problems in self regulatory behaviour, social perception and social interaction may exist with learning disability, but do not by themselves constitute a learning disability. Although learning disability may occur concomitantly with other handicaps or with extrinsic influences, they are not the result of these conditions or influences. The concept of learning disability was recognized the world over as a federally designated handicapping condition. The field now has grown to encompass almost half of all the students receiving special education services in the United States.The school 539

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teachers and educators are confronted with the problem of understanding how best to educate these children, who fail to learn despite an average or above average intellectual capacity. The learning disabled individual possesses a unique set of characteristics which needs to be recognized for an effective educational intervention. There are three types of learning disabilities that are commonly described.3 They are as follows : 1. Dyslexia : The word Dyslexia is derived from the Greek word "dys" meaning difficult and "lexia" meaning words or vocabulary. Commonly interpreted as difficulty in reading, dyslexia denotes a language disorders affecting reading, spelling, speaking and listening. 2. Dysgraphia : The term refers to an unexpected difficulty in learning to write. 3. Dyscalculia : The term refers to a disorder affecting mathematical reasoning and calculations. CLINICAL EVALUATION PROCEDURE

Also, factors such as previous head trauma, plumbism, otitis media, meningities, seizures and its treatment have been shown to be associated with learning disability. Chronic medical conditions like asthma may interfere with learning through absenteeism and or concomitant emotional concerns. Rutter et al (1970)s documented an increase incidence of learning and behavioural problems in children with epilepsy. Farwell et al (1990) 6 suggested that phenobarbital may affect the cognitive function in 2-3 years old children given the medication to prevent febrile seizures and may lead to learning problems. The exact aetiology of learning disability is difficult to prove, nevertheless past medical problems do contribute to the development of learning disability and may even compound the disability by frequent school absenteeism. The exact cause and effect relationship would be difficult to prove. The neurologic disorders like Neurofibromatosis 1, Tuberous sclerosis and children treated with cranial irradation have a higher frequency of learning disability and the ratio of nonverbal to verbal L.D. is reversed, compared with the general population. 7 A. Birth History

An accurate diagnosis with a complete description of a child's learning problem is not possible without a thorough evaluation. The evaluation must identify the academic areas that present problems, the factors that contribute to the problems, the available strengths for compensation and the extent of non-academic difficulties. The clinical evaluation consists of the following :

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Medical assessment including history with spedal emphasis on events at birth, developmental milestones, educational performance and sociocultural background of family. The detailed physical and neurological examination should be performed. The vision and hearing test should be undertaken to detect the sensory defidts if present. Analysis of school performance : school reports, history of failures/condonement and assessment of the child's behavior in school. Assessment of General Cognitive Functioning as measured on standardized tests for intelligence. Assessment of Achievement Level - as measured on educational tests. Assessment of associated behavioral and social problem if any. MEDICAL HISTORY

Events around the perinatal period are extremely important in children with developmental disabilities? 540

Information regarding pregnancy and birth is important to note as factors like prematurity, low birth weight history of perinatal asphyxia may lead to sequelae of learning disability. Lilenfield and Pasamanick (1960)8proposed a range of factors like prolonged labour, malpresentation, cord around neck leading to hypoxic ischemic injury to the brain responsible for learning disability in children. In a series conducted by Davie et al (1972),9Dunn et a/(1971)1~it was consistently reported that Appropriate for Gestational Age (AGA) children faired better academically than Small for Gestational Age (SGA) babies. Thus, prematurity and LBW may be considered as important contributing factors for the development of learning disability. B. Development History

The milestones in d e v e l o p m e n t of speech and language are very important for evaluation of a child with a suspected learning disability. Language Delay

Many children with learning disabilities have history suggestive of delay in language development. They fail to use words, sentences or phrases at an appropriate age or continue to speak in single words. Many of these children also have articulation problems which may persist for a long period through the school age. This delay or imprecision of language use is often carried Indian Joumal of Pediatrics, Volume 68--June, 2001

Approach to teaming Disability

over to learning letters of the alphabet and to reading. Language deficits of reading, writing and spelling have been described as developmental disturbances, reflecting an immature nervous system, u It was also observed that learning disabled children had slow maturation of language skills, especially reading. Therefore, delayed onset of speech may be a symptom of a language disorder in the presence of otherwise normal developmental milestones. Motor Co-ordination Children with learning disability may be slow to sit, walk or run and may have a general clumsiness. Activities such as walking, jumping, catching are often delayed. Children with LD tend to be clumsy and awkward on the playground and are unable to perform simple physical exercises like toe touching or balancing. However, it may be noted that in most learning disabled children, the motor milestone may be normal but and they often demonstrate motor clumsiness and awkward finger movements which are related to the difficulties in motor co-ordination. Bladder Control Generally, bladder control is not delayed in learning disabled children, but a few may have associated enuresis. It was observed that children with enuresis were found to have developmental delays twice as oftenJ2The aforementioned link between enuresis and developmental delay, would suggest that there is a common underlying maturational factor that makes learning disabled children, more vulnerable to develop enuresis as well as behavioural disturbances. SCHOOL HISTORY In depth interviews with parents discussing the problems in the school should be documented in detail. History of past failures, condonements, behavioural problems, child's behaviour in classroom and the teacher's perception of the child behaviour should be noted. The child's report-card to assess the performance in individual subject is very useful in the process of diagnosis of learning disability. FAMILY HISTORY A history of language difficulties or scholastic problems in the parents or other family members should be inquired in each case suspected to be having LD A strong association between a positive family history and occurance of LD has been documented in many studies. The studies conducted by Herman Indian Journal of Pediatrics, Volume 68--June, 2001

(1959)13and Bakwin (1973)14showed that concordance rates for monozygotic versus dizygotic twins was

higher. SOCIAL HISTORY Socioeconomic status as well as education of parents should be recorded. It has been reported that factor like inferior intellectual level, lack of motivation, lack of environmental stimulation and parental indifference to the child's scholastic attainments interfere with the school achievements. A child belonging to an unpriviledge class may show lower performance due to these environmental factors. Also, understanding of socioeconomic status of the family is of great help in planning the interventional program for a child having learning disability. PHYSICAL EXAMINATION Primary learning disability itself has no specific signs found on physical examination. However, physical examination including detailed neurologic examination is important to detect neurological defidts or other handicapping condition in such a child. Neurocutaneous markers like hypopegmentedmacules (ash leaf macules), periungle filromas or shagreen patches, multiple cafe-au-lait spots may be seen in children with learning disability. The presence of dysmorphic features like epicanthal folds, slanting palpebral fissures, microcephaly and polydactly may be an indication of chromosomal defects or associated M.R. NEUROLOGICAL EXAMINATION The clinical neurologic examination is undertaken chiefly to assess the motor co-ordination abnormalities that may be present in children with learning disability. A gross neurologic examination is generally normal in learning disabled children. Some children occasionaly demonstrate difficulty in tandem walking or an abnormal Finger-Nose Test. Mild forms of neurologic signs like asymmetry of reflexes, asymmetric gait or an awkward posture observed in some children with LD suggest neurologic deficit or immaturity of the CNS. The soft, substle or neuromaturational signs are the features, that change over time. These may be present in normal young children, but when present in older children indicate neurologic immaturity. Following soft signs of motor functions, directionality and body space concept should be looked for in a child suspected to having LD. 541

Madhud Kulkami et el Motor Functions

Directionality

a) Repetitive finger tapping/dysdiadochokinesis- the ability to carry out rapid alternating movement on each side is tested in turn.Inability to d o these m o v e m e n t s is c o n s i d e r e d n o r m a l in c h i l d r e n y o u n g e r t h a n 11 years, b u t is i n d i c a t i v e of n e u r o l o g i c i m m a t u r i t y w h e n p r e s e n t in older children.

Left - right confusion - inability to d i s t i n g u i s h between left and right. Delayed if confusion is persistent beyond the age of 12 years.

b) T a n d e m gait - ability to m a s t e r f o r w a r d a n d background gait. Abnormal when not achieved by 7 years of age. c) Sequential opposition of fingers to thumb. d) Mirror movements (synkinesia) e) Motor awkwardness.

Body - Space Concepts

Finger gnosis - ability to recognize, identify and differentiate fingers when touched separately. Delayed if confusion is present b e y o n d 7 ~ years. It is found that children with LD may have the more number of m i n o r neurological signs as c o m p a r e d to n o r m a l children. H o w e v e r , most signs d i s a p p e a r b y 11-12 y e a r - o l d a n d o l d e r c h i l d r e n w i t h LD m a y n o t demonstrate these signs. Shaywitz and Shaywitz is

Tast~ 1. Pre-School Characteristics 9 Significant delay in development of speech. 9 Delay in development of fine motor skills. 9 Difficulty in pronouncing words. Child often has difficulty separating / sequencing sounds in words (cimena for cinema) or blending sounds (Kirket for Cricket) 9 Difficulty or slowness to add new vocabulary words 9 Unable to recall the right word 9 Inabih'ty to rhyme by age 4 years. 9

Difficulty in tying shoe laces

9 Confusion in directionally words and space concepts, left versus right, over versus under, before versus after. 9 Lack of dominant handedness (switches from right hand to left hand between tasks or even while doing the same task) 9 May have trouble learning the alphabet, numbers, day of the week, colors, shapes. 9 May have difficulty telling and / or retelling a story in the correct sequence. TAB~ 2. Primary School Characteristics 9 9 9 9

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Has difficulty decoding single words ( reading single words in isolation ). May be slow to learn the connection between letters and sounds e.g. the sound 'K' goes for both ' C in cat & 'K' in kite. May confuse small words - at - to, said - and, does - goes. Makes typical reading and spelling errors such as : Letter reversals - d for b as in dog for bog. Word reversals - tip for pit. Inversions - m and w , u and n. Transpositions - felt and left. Substitutions - house and home. May transpose number sequences and confuse arithmatic signs. (+-x/=) May have trouble remembering facts. May be slow to learn new skills. Relies heavily on memorizing without understanding. May be impulsive and prone to accidents. Often uses an awkward pencil grip ( fist, thumb hooked over finger, etc. ) May have trouble learning to tell time. May have poor fine motor co-ordination. Appears very dumsy. Indian Journal of Pediatrics, Volume 68--June, 2001

Approach to Learning Disability TABLE3. Middle School Characteristic

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Reverse letter sequences - soiled for solid, brith for birth. Slow to discern and to learn prefixes, suffixes, root words and other reading and spelling strategies. Has difficulty spelling, spells same word differently on the same page. Avoids reading aloud. Has trouble with word problems in mathematics Writes with illegible handwriting, with awkward, pencil-grip or, may avoid writing. Has slow or poor recall of facts Has difficulty with comprehension Has difficulty making friends May not understand body language and facial expression of others. Has trouble with non-literal language ( idioms, jokes, proverbs, slang ) Forgets to hand in homework or to bring in homework Has difficulty with planning and time management.

TABLE4. High School Characteristics

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Reads very slowly with many inaccuracies. Continues to spell incorrectly, frequently spells the same word differently in a single piece of writing. Procrastinates reading and writing tasks. Avoids writing. Has trouble summarizing and outlining. Has trouble answering open-ended questions on tests, prefers objective type of questions. Has poor memory skills Works slowly. Has poor grasp of abstract concepts. Pays little attention to details or focuses too much on them. Misreads information. May not complete assignments; may complete them and not hand them in. Has an inadequate vocabulary. Has an inadequate store of knowledge from previous reading. Has difficulty with planning and time management. TABLE5. Characteristics in Adults with L.D.

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Hide reading problems, many subterfuge. Spell poorly; rely on others. Avoid writing, may not be able to write. Often competent in oral language. Rely on memory; may have excellent memories. May have good spacial talents. Often very good at "reading" people. Have difficulty with planning and organization. Have difficulty with time; often too early, late, or forget appointments. Rely on digital watches; cannot tell time.

termed these signs as neuromaturational signs. These signs are minor, m a y often occur in n o r m a l y o u n g c h i l d r e n a n d are n o t n e c e s s a r i l y r e l a t e d to a n y structural lesion in the brain. Therefore it should be

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noted that soft signs do not provide useful diagnostic criteria for indication of brain dysfunction in learning disabled children and their absence does not rule out the possibility of L.D. Dexterity It has been found that the incidence of left handedness, ambidexiterity and crossed laterality is comparatively h i g h in children w i t h LD. The dexterity s h o u l d be tested in hand, leg, eye and ear. A n u m b e r of behavioural characteristics, academic abilities, perceptual and developmental difference may be present to a greater or lesser extent. The signs and s y m p t o m s as per the age of the child or grade level may be useful for suspecting the diagnosis of learning disability. They are summarized in the Tables 1 to 5.

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LABORATORY TESTS Research studies on learning disabled children have shown that some laboratory tests may be helpful in differentiating them from control group. 16 Electroencephalography studies have shown abnormalities of rate and amplitude in approximately 50% of learning disabled children. Focal or paroxysmal abnormalities have been reported in a small proportion of patients. No specific EEG pattern has been found to be diagnostic of learning disability. 17Therefore, routine EEG studies are suggested only for those children with some evidence of specific seizure disorder. Imaging studies c o m p u t e d tomography and magnetic resonance imaging scans of the brain have failed to show any consistent abnormalities involved in different forms of learning disabilities. Some studies have reported an association of symmetrical temporal lobes instead of asymmetry found in non-dyslexic group. Neuronal migration defects and corpus callosum abnormalities have also been reported? 8 Vision and Hearing Test

A routine opthalmic and hearing test examination for refractory error and hearing test should be undertaken to detect deficits in the sensory system which lead to learning difficulties in children. COGNITIVE ASSESSMENT Cognitive function is measured by a test of general intelligence. The main purpose of this test is to assess the level of intellectual functioning which is taken as an indicator of child's potential for learning. The most commonly used test for school age children is the Weschlers Intelligence Scale for Children (WISC-R) Indian adaptation. The WISC-R consists of 12 subtests based on verbal and nonverbal tasks. Each of the 12 subtests is scored separately as per the age-norm. The six verbal subtests yield a verbal IQ and the six nonverbal subtests yield a performance IQ. The verbal and performance scores are combined to give a full scale/global IQ. A child with learning disability may show a marked discrepancy between verbal and performance IQ scores. Also, a subtest scatter may indicate the disability in a specific area. EDUCATIONAL ASSESSMENT Educational assessment is an integral part of evaluation of a child with LD. 19 It involves the administration of educational tests in the following areas of learning.2~ 544

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Basic Learning Skills. Reading Comprehension Oral Expression Listening Comprehension Written Expression Mathematical Calculation Mathematical Reasoning

There are many educational tests available for this purpose. It not only helps in the diagnostic procedure but also indicates the specific abnormality in the process of learning. However, the test needs to be critically selected for an individual child u n d e r consideration. Any one or more of the following tests may be used by the special educator to complete the assessment. 1. Kauffman Test of Educational Assessment (K-TEA) : Tests in reading, mathematics and spelling. 2. Woodcock - Johnson Psycho Educational Battery (WJPB) : Cluster areas include reading, mathematics and written language. 3. Stanford Diagnostic Reading Test (SDRT) and Stanford Diagnostic Mathematics Test (SDMT). 4. Test of Written Language (TOWL). Test the Written Expression. 5. Wild Range Achievement Test-Revised (WRAT-R) Tests in reading, spelling and mathematics. 6. Peabody Individual Achievement Test (PIAT) The interpretation of test results should be undertaken by an experienced diagnostician. Also, the factors such as emotional factors, ADHD/ADD and neurological disorders need to be taken into consideration while giving the report of educational assessment. In a child with average intelligence an academic achievement two year below the actual grade placement is usually considered indicative of learning disability. DIAGNOSIS

A multidisciplinary approach is essential for diagnosis of LD as there are very few objective diagnostic criteria which are universally acceptable for learning disability. The following guidelines are useful in making the diagnosis : 1. 2.

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Average or above average intellectual functioning No evidence of peripheral sensory defects (visual or hearing) which seriously interfere with learning. Performance 2 years below grade level for the age on the basis of achievements test or achievement score below the 20th percentile. Indian Journal of Pediatrics, Volume 68--June, 2001

Approach to Learning Disability ASSOCIATED BEHAVIOURAL PROBLEMS AND FAMILY DISTURBANCES

The u n d e r l y i n g basis of learning disability is a neurophysiological defect in cognitive processing but the overall effect is a cascade of reactions that seriously affects many other functions. Psychological problems are commonly observed in children with learning disability. 21 These children tend to be easily influenced by others. Some of them may get involved in antisocial activity and risk taking behaviour. Serious emotional disturbances such as low self esteem, temper tantrums may be observed in children with LD. Many children lack self confidence. Some demonstrate difficulties in a p p r o p r i a t e l y m a n a g i n g t h e m s e l v e s in social situations. All these issues place a great stress on the family. Parents of learning disabled children are often frustrated by problems they face in trying to get help for their child's problem. Many of them deny it. Most parents are deeply concerned about future educational possibilities and economic limitations that their child may face. ADHD AND LEARNING DISABILITY

A reciprocal relationship exists between learning and attention. Some children have difficulty in paying attention secondary to their inability to understand what is being taught or may have a primary attention deficit, is Distinction between learning disability and ADHD is often difficult because most of these childhood disorders have overlapping features. However learning Disability and ADHD often coexists. The shared symptoms include distractibility, disorganization, impulsiveness, poor social skills, poor self control and lack of self esteem. These children show higher rates of anxiety than children diagnosed with isolated ADHD and have clear symptoms of this disorder, but may have equally serious deficits in communication. Children with learning disability only by contrast characteristically demonstrate phonologic and logic problems. REMEDIAL EDUCATION

Remedial or special education includes specific teaching strategies and teaching materials. It is a planned intervention designed to reduce, eliminate or preclude deficiencies in specific learning areas. 15An Individual Education Program (IEP) is formulated by the remedial teacher taking into consideration the Indian Journal of Pediatrics, Volume 68--June, 2001

child's strengths and weaknesses in such areas. Individualized supportive education by the remedial teacher to learning disabled children in regular school helps the students to catch up with education in regular class. It is important that the remedial teacher and the regular class-teacher work closely to plan the duration of remedial instruction and activities to teach students in the regular and remedial class to improve their performance. CONCLUSION

Learning disability forms an important cause of failure in school in otherwise capable children. The learning disabilities are often accompanied by problems of attention and concentration, organization, mood and emotions and feelings and social interaction. A multidisciplinary approach is essential for early recognition of this disability. The appropriate curriculum adjustment, help the child attain his / her maximum educational potential and become a productive and contributing adult member of the society. REFERENCES

1. Hornsby B. Overcoming Dyslexia : A straight forward guide for families and teachers. Singapore : PG Publishers Pvt. Ltd. 1994. 2. Hammil DD. On defining learning disabilities An emerging consensus. J Learn Disabil 1990; 23 : 73-84. 3. Rutter M. Prevalence and types of Dyslexia. In Benton AL, Pearl D, eds. Dyslexia, An Appraisal of Current Knowledge. New York: Oxford University Press, 1978;328. 4. Erenberg G. Learning Disabilities; An overwiew. Seminars in Neurology 1991; 11 : 1-6. 5. Rutter M, Tizard J, Whitemore K. Education, health, and behaviour. London: Longman, 1970. 6. Farwell J, Lee YJ, Hirtz DG. Phenobarbital for febrile seizures-effects on intelligence and on seizure recurrence. N Engl J Med 1990; 322 : 364-369. 7. Cohen BH. Neurologic causes of learning disabilities. Seminars in Neurology 1991; 11 : 7-13. 8. Lilienfeld AM, Pasamanick B. The associationof mental and factors. With the Development of mental delivery. Am J Mental Deficiency 1960; 60 : 557. 9. Davie R, Butler N, Goldstein H. From birth to seven: a report of the national child developmentstudy. Br Med J 1972; 3 : 4. 10. Dunn H, Cricton JU, Robertson AM et al. Late prognosis in children of low birth weight: Proceedings of the XIIIInternational Congress of Pediatrics; Vienna. Academy of Medicine 1971; 33-38. 11. Zuckerman B, Chase C. Specific Learning Disability and Dyslexia: A language based model. 1984 year book medical publishers; 249-276. 12. Lewis Melwin: Enuresis in children. In Child and 545

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