Medical Aspects of Specific Learning Disabilities (SpLD)

1. Medical Aspects of Specific Learning Disabilities (SpLD) Sunil Karande Associate Professor of Pediatrics Learning Disability Clinic Department of Pediatrics LTM Medical College & General Hospital Mumbai

3. Specific Learning Disabilities (SpLD) • Group of developmental disorders • Significant unexpected, specific and persistent difficulties in the acquisition and use of reading (dyslexia), writing (dysgraphia) or mathematical (dyscalculia) abilities, • despite conventional instruction, normal intelligence, proper motivation and adequate socio-cultural opportunity

4. The child with SpLD is one who does not meet expectations for academic performance in school but has intelligence in the normal range “a severe discrepancy between achievement and intellectual ability in one or more of the following areas: Oral expression Listening comprehension Written expression Basic reading skill Reading comprehension Mathematical calculations Mathematical reasoning”

5. What is not SpLD !!!! • “Slow learners” (IQ 71 to 84) • Mental retardation (IQ ≤ 70) • Visual handicap (>60% disability) • Hearing handicap (> 60% disability) • Physical handicap (e.g. cerebral palsy) • Language barrier • Emotional problems / Chronic medical problems • Psychiatric disorders (e.g. depression)

6. Brief History of SpLD • 1878: Dr. Kussmaul (Germany) described a man with normal intelligence but unable to read in spite of an 'adequate' education. He called this condition “reading blindness” • 1896: Dr. Pringle Morton (UK) described 14- year-old boy with reading difficulty: The teacher:- “he would be the smartest lad in the school if instruction were entirely oral”

7. 1925: Dr Samuel Orton (USA) proposed the theory of “specific learning difficulty” • 1936: Anna Gillingham and Bessie Stillman published "Remedial Training for Children with Specific Disability in Reading, Spelling and Penmanship" • 1963: Dr. Samuel Kirk (USA) first used term “learning disabilities” • 1969: “The Children with Specific Learning Disabilities Act (USA)” passed

8. 1977: Public law fine tuned ensuring rights of American children with SpLD to 'appropriate evaluation' and 'management' of their problem • “every SpLD child will participate in same curriculum and have same academic objectives”

9. History of SpLD in India • 1987: SNDT College starts B.Ed. (Special Education) course: Special Educators for remediation available • 1992: Parent group start “lobbying” for recognition of SpLD so that these children continue education in regular schools • 1995: Maharashtra Dyslexia Association formed by parents of SpLD children

10. 1996: L.D. clinic at LTMG (Sion) Hospital started by Prof. Madhuri Kulkarni • 1996: Govt. of Maharashtra issues G.R. which grants provisions for first time in India; but for standards IX and X only • 1999: ICSE and CBSE boards also grant provisions

11. 2000: Provisions extended from standard I to XII 2003: Provisions extended to college courses; Seats “reserved” for SpLD in physically handicapped category in colleges, including professional courses

12. Facts about SpLD • 5-15% school population • Intrinsic to the individual • Invisible Handicap • ? Genetic in origin • Due to CNS dysfunction • Chronic life-long conditions

13. Genetics Of Dyslexia • In 1950, Hallgren suggested that dyslexia was an autosomal dominant disorder • Recent findings: • Dyslexia is a genetically heterogeneous and complex trait that does not show classical mendelian inheritance • Several chromosomal regions have been reported to contain genes affecting reading disability (chromosome 1, 2, 3, 6, 15, 18)

14. Genetic Disorders Associated with SpLD • Sex chromosome anomalies: • XXY, XYY, fragile X syndrome, XO (Turner’s) • Syndrome NF1 and other neurocutaneous disorders • PKU

15. Perinatal Risk Factors • Low birth weight • Obstetrical complications: • Birth asphyxia • Intraventricular hemorrhage

16. What happens in dyslexia? • Deficits in “phonologic awareness” • Phoneme: smallest discernible segment of speech • "bat" consists of three phonemes: /b/ /ae/ /t/ (buh, aah, tuh) • Poor awareness that words, both written and spoken, can be broken down into smaller units of sound and; letters constituting printed word represent sounds heard in spoken word

17. How does SpLD present? • Failure to achieve school grades commensurate with intelligence • Repeated spelling mistakes, untidy / illegible handwriting, poor sequencing, inability to perform simple mathematical calculations • School failure / under-achievement • Adverse impact on self-image, relationships • If undetected: school drop-outs and even anti-social elements

18. EEG studies • EEG abnormalities in 50% but no specific pattern • Above minor changes no longer considered valid or of any value • No role in the evaluation of LD

19. Neuroimaging • Absence of usual asymmetry of planum temporale (portion of temporal lobe lying posterior to Heschl’s gyrus) • Left is usually larger than right • Perhaps right being larger than normal is due to failure of neuronal pruning

20. Not certain if brain changes localized to specific areas, or if interaction between different areas important in causing SpLD CT / MRI scans not useful New research tools: fMRI, PET / SPECT scans

21. Functional Imaging in Dyslexia • 13 studies: no consistent pattern of hypo- or hyper activation • Abnormalities found in multiple areas, sometimes both hemispheres • Most common: hypo activation in left temporal lobe during reading tasks • Some studies: activation increased after remedial therapy for dyslexia

22. Attention deficit hyperactivity disorder (ADHD) • Affects 8-12% of children • 3 sub-types: • ADHD-I: inattention • ADHD-HI: impulsivity and hyperactivity • ADHD-C: have both • At risk for poor school performance • 20-25% ADHD children have SpLD and vice versa

23. Evaluation Procedure • Letter from School Principal • Multi-disciplinary approach: • Medical / Neurological examination • Vision, Hearing tests • Analysis of school reports • IQ testing (WISC test) • Educational assessment • Psychiatric assessment, if required • Case conference / Final diagnosis • Counseling before Certificate issued • Takes 2-3 wks to complete

24. Data from LTMGH LD clinic

25. At time of diagnosis: Each child’s parents counseled: • SpLD: its meaning, treatment, prognosis • Importance of remedial education • Provisions at school examinations and at board examinations in future • Child and parents to choose whether to avail all available provisions or only some of them • Choice to be made in consultation with school teachers / remedial teacher • About ADHD if co-morbidity

26. Remedial Education • Cornerstone of treatment of SpLD • Should ideally begin early, when child in primary school • Special Educator formulates Individual Education Program (IEP) • Hourly sessions twice / thrice wkly for few yrs

27. Expensive (Rs. 150-800/ session) Most schools do not employ special educators as staff members Children have to necessarily take remedial education from “private” special educators Parents not adequately knowledgeable about remedial education

28. Role of Provisions • SpLD distorts scores causing them to be too low • Provisions formulated to help SpLD children continue in regular mainstream school • Provisions function as ‘corrective lens’: distorted array of observed scores back to where they ought to be • Provisions serve to "level the play field“: academic performance now commensurate with intellectual ability

29. Provisions at SSC board examination • Extra time of 30 mins for written tests, spelling mistakes overlooked • Employing writer for children with dysgraphia • Exemption of 2nd language, substituting with work experience subject • Exemption of standard X mathematics (algebra and geometry), substituting with standard VII mathematics and work experience subject • Choice is to be made from a range of 39 work experience subjects [e.g. Typewriting (English), Introduction to Computer, Book Binding, Hand Embroidery, Drawing & Painting]

30. Impact of Provisions • 60 children at SSC examn with provisions compared with performance at last annual school examn before diagnosis of SpLD • Improvement in mean % total marks (63.48 ± 7.86 vs. 40.95 ± 7.23 ) [mean % difference = 22.53, P < 0.0001] • Children who availed exemption of 2nd language or opted for lower grade mathematics scored better marks (P < 0.0001 and P = 0.0009, respectively)

31. Experiences with Parents • Just do not accept diagnosis • Do not begin remedial education • Instead private tuitions • Omit remedial education early • Refuse provisions as it restricts future career options (e.g., child who has opted for lower grade of mathematics cannot later have career in engineering)

32. Experiences with Schools • Regular Awareness Workshops conducted • School Principals targeted first • School Teachers sensitized to suspect SpLD • Initially, many schools uncooperative • Implementation of Govt. rules mandatory • Cannot detain child if provisions not given

33. Wish List • Better awareness amongst parents, school authorities, doctors • Remediation Center in every school • Standardized psychological and educational tests in all languages • Provisions made available to all SpLD children • Tests to identify children “at risk for SpLD” early • Identification of genetic markers for risk of SpLD • Neuroimaging studies (fMRI and PET) to unravel etiology

34. THANK YOU