Specific learning disorders

Dr.Pawan GhanghoriyaAssociate professor and HeadDepartment of PediatricsNSCB Medical College Jabalpur

A type of Neurodevelopmental Disorder that impedes the ability to learn or use specific academic skills (e.g., reading, writing, or arithmetic), which are the foundation for other academic learning.

Pathology There may be underlying abnormalities in

cognitive processing (e.g., deficits in visual perception, linguistic processes, attention, or memory, or a combination of these)

“problem of basic psychological processes involved in understanding or in using language, spoken or written, that may manifest itself in the imperfect ability to listen, think, speak, read, write, spell, or to do mathematical calculations.”

 “Children with learning disabilities are not ‘dumb’ or ‘lazy.’ In fact, they usually have average or above average intelligence. Their brains just process information differently.”

Children with specific learning disorder are sometimes described as having “unexpected academic underachievement,” meaning that the child’s test scores or grades are significantly below what would be expected given his/her thinking and reasoning ability (cognitive ability).

Epidemiology An estimated 5 to 15 percent of school-

age children (and about 4 percent of adults) experience specific learning disorders.

More common in males than in females (ratios range from about 2:1 to 3:1)

Reading disorder (dyslexia) is the most common.

An estimated 70 to 80 percent of those with a learning disorder have a reading disorder.

Specific learning disorder can vary in severity

Mild: able to compensate or function well when provided with appropriate accommodations or support services.

Moderate: Significant difficulties with learning, requiring intensive and specialized teaching and some accommodations or supportive services. Unlikely to become proficient.

Severe: Severe difficulties with learning, affecting several academic areas and requiring ongoing intensive specialized teaching. May not be able to complete all activities completely

Development and Course

Specific learning disorder is lifelong, but the course and clinical expression are variable, in part depending on the interactions among the task demands of the environment, the range and severity of the individual's learning difficulties, the individual's learning abilities, comorbidity, and the available support systems and intervention. Nonetheless, problems with reading fluency and comprehension, spelling, written expression, and numeracy skills in everyday life typically persist into adulthood.

Changes in manifestation of symptoms occur with age, so that an individual may have a persistent or shifting array of learning difficulties across the lifespan.

Age of presentation Early signs of learning difficulties may appear

in the preschool years (e.g., difficulty learning names of letters or counting objects), but they can only be diagnosed reliably after starting formal education.

The learning difficulties are seen by the early school years in most children. However, for some the learning difficulties may not be apparent until later, when academic demands are greater.

preschool-age children - a lack of interest in playing

games with language sounds (e.g., repetition, rhyming), and they may have trouble learning nursery rhymes. frequently use baby talk, mispronounce words, and have trouble remembering names of letters, numbers, or days of the week.

Kindergarten-age children with specific learning disorder may be unable to recognize and write letters, may be unable to write their own names, or may use invented spelling. Kindergarten-age children also may have trouble connecting letters with their sounds (e.g., letter b makes the sound /b/) and may be unable to recognize phonemes (e.g., do not know which in a set of words [e.g., dog, man, car] starts with the same sound as "cat")

elementary school-age children - primary grades (grades 1-3) reading aloud is slow, inaccurate, and effortful. difficulty remembering number facts or arithmetic procedures for adding, subtracting

middle grades (grades 4-6) may mispronounce or skip parts of long, multisyllable words (e.g., say "conible" for "convertible," "aminal" for "animal") and confuse words that sound alike (e.g., "tornado" for "volcano"). They may have trouble remembering dates, names, and telephone numbers. poor comprehension with or without slow, effortful, and inaccurate reading. They may get the first part of a word correctly, then guess wildly (e.g., read "clover" as "clock"), and may express fear of reading aloud or refuse to read aloud.

adolescents may have mastered word decoding, but reading remains slow and effortful, and they are likely to show marked problems in reading comprehension and written expression (including poor spelling) and poor mastery of math facts or mathematical problem solving

continue to make numerous spelling mistakes and read single words and connected text slowly and with much effort, with trouble pronouncing multisyllable words. They may frequently need to reread material to understand or get the main point and have trouble making inferences from written text. Adolescents and adults may

avoid activities that demand reading or arithmetic (reading for pleasure, reading instructions).

Difficulty reading out loud Poor reading comprehension Struggling to write papers and essays Trouble understanding lectures Difficulty holding a pencil Signs that a child might have a learning disability

tend to appear in elementary school. For example, difficulty learning the alphabet, problems with following directions, trouble transforming thoughts into written words and misreading math problems are all possible indicators of a specific learning disability.

Risk and Prognostic Factors

Environmental -Prematurity or very low birth weight, prenatal exposure to nicotine, perinatal injury

Genetic and physiological- aggregate in families, relative risk of specific learning disorder in reading or mathematics is substantially higher (e.g., 4-8 times and 5-10 times higher, respectively) in first-degree relatives of individuals with these learning difficulties compared with those without them.

frequently found in association with a variety of general medical conditions (e.g., lead poisoning, fetal alcohol syndrome, or fragile X syndrome).

Consequences of Specific Learning Disorder

Lower academic attainment, Higher rates of high school

dropout(>150%), Lower rates of postsecondary

education, High levels of psychological distress

and poorer overall mental health, Higher rates of unemployment and

under-employment, Lower incomes

DSM V Criterias

Criterion A refers to the key characteristics of SLD (at least one of six symptoms of learning difficulties that have persisted for at least 6 months despite the provision of extra help or targeted instruction).

Criterion B refers to measurement of those characteristics (the affected academic skills are substantially and quantifiably below those expected for age and cause impairment in academic, occupational, or everyday activities, as confirmed by individually administered standardized achievement measures and comprehensive clinical assessment).

1. Difficulty reading (e.g., inaccurate, slow and only with much effort)

2. Difficulty understanding the meaning of what is read3. Difficulty with spelling4. Difficulty with written expression (e.g., problems with

grammar, punctuation or organization)5. Difficulty understanding number concepts, number

facts or calculation6. Difficulty with mathematical reasoning (e.g., applying

math concepts or solving math problems) The symptoms must have continued for at least six months despite targeted help.

Criterion C refers to age at onset of problems (during the school-age years, although may not fully manifest until young adulthood in some individuals), and

Criterion D specifies which disorders (Intellectual Disabilities, uncorrected auditory or visual acuity problems, other mental or neurological disorders) or adverse conditions (psychosocial adversity, lack of proficiency in the language of instruction, inadequate instruction) must be ruled out before a diagnosis of SLD can be confirmed.

Coding

Specify if: 315.00 (F81.0) With impairment in reading: Word reading accuracy Reading rate or fluency Reading comprehension 315.2 (F81.81) With impairment in written expression: Spelling accuracy Grammar and punctuation accuracy Clarity or organization of written expression 315.1 (FBI .2) With impairment in mathematics: Number sense Memorization of arithmetic facts Accurate or fluent calculation Accurate math reasoning

What changes were made to SLD in DSM-5?

1) one overarching category of SLD with ‘specifiers’ to characterize the specific manifestations of learning difficulties at the time of assessment in three major academic domains, namely reading, writing, mathematics (e.g., SLD With impairment in reading)

2) Elimination of the IQ-achievement discrepancy requirement and its replacement with four criteria (A – D), all of which must be met

‘SLD is a clinical diagnosis that is not necessarily synonymous with ‘learning disabilities’

Differential Diagnosis

Normal variations in academic attainment.

Intellectual disability (intellectual developmental disorder)

Learning difficulties due to neurological or sensory disorders

Neurocognitive disorders Attention-deficit/hyperactivity disorder Psychotic disorders Communication Disorders

Learning Disorders must be differentiated from normal variations in academic attainment and from scholastic difficulties due to lack of opportunity, poor teaching, or cultural factors. Inadequate schooling can result in poor performance on standard

Comorbidities

Neurodevelopmental disorders (e.g., ADHD(15-35%), communication disorders, developmental coordination disorder, autistic spectrum disorder)

Mental disorders (e.g., anxiety disorders, depressive and bipolar disorders).

These comorbidities do not necessarily exclude the diagnosis specific learning disorder but may make testing and differential diagnosis more difficult, because each of the cooccurring disorders independently interferes with the execution of activities of daily living, including learning