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• Evolution of concept
• Concept and approaches
• Epidemiology
• Pathophysiology
• Assessment and Management
• Prognosis
• Issues Indian Context
• Conclusion
• Evolution of concept
• Concept and approaches
• Epidemiology
• Pathophysiology
• Assessment and Management
• Prognosis
• Issues Indian Context
• Conclusion
EVOLUTION OF CONCEPT
1877
• Kussmaaul proposed a term “word blindness” or caecitas verbalis for an acquired loss of words and introduced visual analogy
1887
• Berlin first used the term “dyslexia” in his monograph referring to acquired loss of reading ability
1892
• Dejerine deduced lesion in medial and inferior portion of left occipital lobe could lead to dyslexia- “brain letter box”
1896• Pringle Morgan was first to note a case of dyslexia
1917
• Hinshelwood defined word blindness as pathological condition caused by disorder of visual centers of brain and caused difficulty in interpreting written language
EVOLUTION OF CONCEPT
1937
• Orton (regarded as father of Dyslexia society) observed children with reading problems had near average or above average IQ
1962• The term “learning disability” appeared in print (Kirk)
1977
• US passed a law stating all school must provide special education to the child with LD. IQ discrepancy formula given
1985
• Between 1985 to 2000 several authority gave different definitions for LD
1990…• Advances in the research – neurobiology and genetic
EVOLUTION OF CONCEPT
• Earlier understanding of LD was more in terms of medical model
– Explanation in terms of brain damage or brain dysfunction
• Absence of hard evidence lead to development of the educational framework for defining from 1960s
– Emphasis on discrepancy
– Visuo- motor problem
• From 1980s onwards US National Joint Committee on LD formulated the concept involving all the previously concerned discipline
• 1990 onwards more emphasis on the dimensional nature of problem rather than categorical
– Adopted more by researchers (yet to be adopted by practitioners)
2 major factors that have emerged • Life span approach • Language based problem
Pratibha Karanth, 2003
• Evolution of concept
• Concept and approaches
• Epidemiology
• Pathophysiology
• Assessment and Management
• Prognosis
• Issues Indian Context
• Conclusion
CONCEPTS
• Disorders interfering with the acquisition and use of one or more of the following academic skills: oral language, reading, written language, mathematics
NJCLD, 1988
• These disorders affect individuals who otherwise demonstrate at least average abilities essential for thinking or reasoning
• Learning Disorders are distinct from Intellectual Developmental Disorders
Larry B. Silver,2001
CONCEPTS
UK
Learning disability includes the presence of:
• Significantly reduced ability to understand new or complex information, to learn new skills (impaired intelligence)
• Reduced ability to cope independently (impaired social functioning)
• Started before adulthood, with a lasting effect on development
Eric emersion 2010
CONCEPTS
• DSM (DSM-III), the issue of problems with learning was first addressed“Academic Skills Disorders” AXIS II
• Motor and language difficulties also addressed under “Motor Skills Disorders” - category for fine motor/handwriting difficulties
• “Communications Disorders” - categories for Receptive Language and for Expressive Language Disorders
• “Specific arithmetical retardation” – ICD 9 and “Developmental arithmetic disorder”- DSM III
• Developmental expressive writing disorder – DSM III
CONCEPTS:ICD Vs DSM
DSM 5 has Specific Learning Disorder as a single overall diagnosis incorporating deficits that impact academic achievement
Criteria describes shortcoming in general academic skillDetailed specifier for reading, mathematics and written expression
Both require evidence of a substantial discrepancy between scores on reading achievement test and measured intelligence
CONCEPTS
Types :
• Dyslexia
• Dyscalculia
• Dysgraphia
Associated deficits and disorders:
• Auditory Processing Deficit
• Visual Processing Deficit
• Non-Verbal Learning Disabilities
• Executive Functioning Deficit
National center for learning disability,2014
APPROACHES
• Difference between aptitude and achievement
• Difference between IQ and achievement test scores
Discrepancy
• Multiple domains
• Reading, mathematics , written expression, language
Heterogeneity• No sensory disorder,
mental deficiency, emotional disturbance
• No economic disadvantage, linguistic diversity or inadequate instructions
exclusion
Individuals with Disabilities Education Act (IDEA),2004
No change in this discrepancy approach since 1977 when first approved by US law
APPROACHES- STATIC MODELS
Ability achievement discrepancy
Difference between intellectual ability and performance
No difference in identification with other model
Low achievement model
Student performing below a certain threshold
Doesn’t facilitate whether the child’s low achievement is proportionate to the ability
No distinguish high ability student with average achievement
Intraindividual discrepancy
model
Uneven profile of cognitive measures
Over identification
Kavale 2001
APPROACHES
CRITICISM
• With a low IQ score it is difficult to show an even lower reading test score: introduces a bias against diagnosing dyslexia in less able children
Miles and Haslum (1986)
• Delay in intervention until student’s achievement is low
• Delayed intervention might result to refractory to intervention
• Even criticized as “wait to fail” model
• Overidentification of students who are disadvantaged, ethnic minority, display oppositional behavior
Fletcher, 2004
APPROACHES
RESPONSIVENESS TO INTERVENTION AS DEFINING MODEL:
• Universal screening of all students for reading difficulties in the early school years
• Placement in early intervention programs
• Students can be identified with LD if they maintain deficient achievement, do not adequately respond to increasingly intense instructions
Fletcher, 2004
APPROACHES
RESPONSE TO INTERVENTION- ADVANTAGES
• Shifting of focus from eligibility to concerns about providing effective instruction
• No waiting for students to meet IQ-discrepancy criteria (wait to fail) to identifying students who need intervention as early as possible and providing it immediately
• Not dependent on teacher referral that could be disproportionate
Douglas Fuchs, 2006
• Evolution of concept
• Concept and approaches
• Epidemiology
• Pathophysiology
• Assessment and Management
• Prognosis
• Issues Indian Context
• Conclusion
EPIDEMIOLOGY
National centre of learning disabilities, 2014
EPIDEMIOLOGY
• Lifetime prevalence of specific learning disorders (SLD) in age groupfrom 3 to 17 years of age is 9.7%
– Those with special health care needs (28%)
– Typically developing children (5.4%)
• 2.5 million public school students , 5% of all students in public schools—were identified as having learning disabilities in 2009 in US
National center of learning disabilities, 2014
• Reading disability accounts for 80-90% of all learning disabilities
• Boys> girls
(Lerner et al, 1989; Altarac et al ,2007)
EPIDEMIOLOGY:INDIASTUDY N Urban/ rural Place Tools RESULT
Yadav et al, 2008 N=800 Rural AllahabadSchool
Teachers opinionAchievementrecords
2.25%
Vijayalaxmi , 2009 N=1134 Urban BangaloreSchool
NIMHANS battery
15.17%
Mogasale et al,2011
N=1134 Urban Bangalore,school
NIMHANS battery
15%
Choudhary et al,2012
N=500class 3-5
urban Bikanerschool
Dyslexia Assessment Questionnaire
10.25%
Dhanda and Jagawat, 2013
N=1156 Rural JaipurSchool
IPS questionnaire 12.8%
Arun et al, 2013 N=2402Class 7-12
Urban Chandigarh school
NIMHANS battery
1.58%
Variability may be due to• Rural urban • Teacher screening only • Language differences • Socio economic status • Teacher interview plus performance • Methods of assessment• ?Geographical variation
EPIDEMIOLOGY
National center of learning disabilities, 2014
CORE PROBLEMS
• Receptive language- difficulty to process speech sounds
• Visual perception defects-misinterpretation of words
INPUT
• Sequencing
• Abstraction
• OrganizationINTEGRATION
• Working: Information fragment into full concept
• Short term: information recall
• Long term: metacognitive skills like studying , inability to recall
MEMORY
• Language problems
• Motor problems OUTPUT
Turnbull et al, 2004
MANIFESTATIONS
READING
• Slow, hesitant word by word reading
• Reading without punctuation
• Mirror reading, word guessing
• Omission substitution, addition of words
• Understanding, recall and drawing inference
WRITING
• Avoiding or slow writing
• Awkward pencil holding
• Poor handwriting, spelling, size inconsistency, mixing small and capital letters
• Transposition, mirror writing, add or omit letters in words
MATHEMATICS
• Longer time
• Mistakes in sums involving 0
• Difficulty in keeping tenth, hundredth or thousand place
• Carry over or borrowing problem
• Difficulty in word problems
ASSOCIATED PROBLEMS
BEHAVOURAL
• Laying blame on teachers
• Making excuses for bad behavior
• Exhibiting “I give up” attitude
• Avoiding confrontation about school
Social
• Poorly accepted by friends
• Greater risk for social alienation from teachers and classmates
• Less social activity
• Impulsive answers
• Inappropriate answers
• Get bullied
Emotional
• Remain aloof
• Feeling low
• Anger and frustration
• Poor self esteem
• Receive a more negative assessment of social skills difficulties• Poor self-esteem, frustration, and other barriers to developing social skills• Lead to behavioral problems
Forness and Kavale,1996
MOTOR INCORDINATIONAmong 137 children with LD , 50.4% of the children performing below the 15th percentile on the Movement assessment Battery(balance coordination, manual dexterity, ball skills etc.)
Vuijk et al, 2011
COMORBIDITIES
? Shared etiologic and neurocognitive risk factors
ADHD
Language Impairment
Speech Sound
Disorder
Learning disability
ADHD, SSD, and LI are all likely to be apparent earlier and can thus indicate a child’srisk for later reading problems
Pennington et al 2009
COMORBIDITIES
• Willcutt et al, 2000
• N=209 twins with reading disability
• n-=192 without RD
• DSM-III Diagnostic Interview for Children and Adolescents, Parent Report Version
• Child self-report version of the Diagnostic Interview for Children and Adolescents
COMORBIDITIES
STUDY SAMPLE TOOLS RESULTS
Margari et al 2013
448 Italian children 7-16 yrs.
• DSM IV TR• Standardizeddiagnostic tests for neuropsychological and psychopathological evaluation
Total Comorbidity % -58.3%ADHD-33%Anxiety disorder-28.8% Mood disorder -9.4% Language disorder 11% Motor coordination disorder 17.8%
Gallegos et al, 2012
120 Mexican children with LD and 120 without LD9 to 12 years old
• LD via school records
• Spence Children’s Anxiety Scale
• Children’s Depression Inventory
Anxiety –23.3% VS 11.5%
Depression-32% VS 18%
COMORBIDITIES
The median LD prevalence rate across the 17 ADHD Studies was 31.1%, Control: median prevalence of 8.9%
The prevalence rate of ADHD in LD a median prevalence of
38.2% across studies
Control: 5%
DuPaul and Stoner (2003) reviewed 17 studies conducted between 1970s to 1990s that reported the percentage of students with
1982- 19931978-1993
• Publications from the past decade (i.e., 2001–2011) were reviewed
• Rates of LD in students with ADHD ranged from 8% to 76% of students (Median = 47%, M = 45.1%)
Dupaul et al 2012
• Evolution of concept
• Concept and approaches
• Epidemiology
• Pathophysiology
• Assessment and Management
• Prognosis
• Issues Indian Context
• Conclusion
ETIOPATHOGENESIS-THEORIESTHEORY EXPLAINATION LIMITATIONS
Phonological Specific impairment in the representation, storage, and/or retrieval of the speech sounds
Inability to explain the occurrence of sensory and motor disorders in dyslexic individuals
The rapid auditory processing theory
failure to represent short sounds with fast transition would cause difficulty in response to the acoustic events with phonemic contrast like /ba/ vs /da/
Same
Visual theory Abnormality in the magnocellular layers of lateral geniculate nucleus
Failure to replicate the visual findings
Scerri and Schulte Korne, 2010
ETIOPATHOGENESIS-THEORIES
THEORY EXPLAINATION LIMITATIONS
Cerebellar theory • Motor control, speecharticulation, automatization of repetitive task like driving reading
• Brain imaging studies also show anatomical, metabolic and activation differences
• Outdated view of the motor theory of speech
• Cases of normal phonological development despite severe dysarthria or apraxia of speech
The magnocellular (auditory and visual) theory
Combines both auditory and visual theoriesGeneral impairment in magnocellular pathwaysVisual, auditory and tactile sensory modalities affected
• Each theory can only explain a proportion of individuals with dyslexia
• Possibility that each theory may account for different sub-sets of dyslexia brought about by different etiologies
Scerri and Schulte Korne, 2010
ETIOPATHOGENESIS-THEORIES(3 TIER)
Biological
• Left hemisphere disconnection
cognitive
• Phonological deficit
• Poor Graph-phoneme knowledge
Behavioral
• Poor reading
• Poor phoneme awareness
• Poor STM
• Poor naming speed
ENVIRONMENTAL FACTORSTeaching method Cultural factors Socio economic factors
Frith, 1999
ETIOPATHOGENESIS-THEORIES(3 TIER)
Biological
• Frontal temporal area
Cognitive
• Phonological deficit
• Attention deficit
• Poor inhibitory control
• Poor graph-phoneme
Behavioral
• Poor planning
• Poor achievement
• Poor reading
• Poor naming skill
ENVIRONMENTAL FACTORSTeaching method Cultural factors Socio economic factors
Frith, 1999
ETIOPATHOGENESIS-THEORIES(3 TIER)
Biological
• Magnocellularabnormality
cognitive
• Slow temporal processing
• Auditory and visual deficit
• Phonological deficiit
Behavioral
• Poor tone
• Poor reading
• Poor coordination
• Poor speech development
ENVIRONMENTAL FACTORSTeaching method Cultural factors Socio economic factors
Frith, 1999
ETIOPATHOGENESIS(LANGUAGE)
• 30 dyslexic children from urban India(New Delhi ) English medium school
• Hindi and English word reading task
• A significantly greater accuracy for Hindi word reading than English (42% vs 30%)
Language Phonetic Orthographic
Hindi 65% 15%
English 57% 35%
• Reading strategies are affected in part by the orthographic transparency of the language
• Hindi- Shallow(spelling-sound correspondence is direct)• English- Deep(reader must learn the arbitrary or unusual pronunciations of
irregular words.)
Ashum Gupta, 2006
NEUROBIOLOGY
• First reported by Dejerine in 1891 that damage to (angular gyrus) resulted in variable degree of impairments in reading and writing
• Autopsy
– Symmetrical Plannum Temporale - triangular structure on the superior surface of the temporal lobe inside the Sylvian fissure (SF) and it is a region of the cortex that falls within the Wernicke’s area( left hemisphere)
– cortical malformations in the form of neuronal ectopias, architectonic dysplesias (focally distorted cortical architecture) and microgyria (abnormal infoldings)
– Disorganized magnocellular layers of visual pathway and smaller medial geniculate nucleus in left of auditory pathway
SO Wajuihian ,2011
NEUROBIOLOGY
• MRI studies
– Studies divided in the symmetry of PT
– higher degrees of asymmetry of the temporal lobes
– No consistent finding
SO Wajuihian ,2011
NEUROBIOLOGY -FUNCTIONAL
STUDY SAMPLE SIZE
TASK FINDING
Corina et al, 2000 8 case 8 controls
Phonological and lexical auditory judgement
Activation in right than left in left temporal gyrus(phon) Less activity in b/l middle frontal gyrus and more activity in left orbital frontal cortex (lexical)
Shulz et al, 2008 16 case 13 control
Identical sentence reading
Decreased activation of frontal and inferior parietal regions of LH
Richards et al, 2008 18 case 21controls
Phoneme mapping task
Greater functional connectivity between left inferior fronytal gyrus to right
NEUROBIOLOGY -FUNCTIONAL
STUDY SAMPLE SIZE
TASK FINDING
Richlan et al, 2010 15 cases 15 controls
Phonological lexicaldecision task
Dysfunction in regions of left occipito-temporal accompanied by absent responsiveness in phonological regions of inferior frontal gyrus
Rimrodt et al, 2009 15 case 15 control
Sentencecompletion to word recognition
areas associated with linguistic processingMore activation
NEUROBIOLOGY -FUNCTIONAL
Meta analysis 7 original studies on functional abnormalities in the dyslexicActivation Likelihood Estimation (ALE)
Underactivationinferior parietal, superior temporal, middle and inferior temporal fusiform regions of the left hemisphere
Overactivationinferior frontal gyrus primary motor cortex anterior insula
• Contrary to previous findings of compensatory activation of right hemisphere and posterior region
Richan et al, 2009
Left Inferior frontal gyrus
(Activates during phoneme/word
production/ articulation )
Left Parietal-temporal
(word analysis or phonological
decoding )
Left occipital-temporal
(word form recognition )
Compensatoryincrease
Hypoactivation
No Corresponding Increased activation – RIGHT SIDED Posterior regions as opposed to previous meta analysis
NEUROBIOLOGY ANATOMICAL
• White Matter decreases in the left frontal and parietal portions of the arcuate fasciculus
• Gray matter density decrease in dyslexics in the key area of functional underactivation (left medial temporal gyrus)
• Family study – the grey matter changes present from beforehand/ as a risk factor
• Altered connectivity in specific WM tracts ( left superior longitudinal fasciculus) compromise the acquisition of language and cognitive skills important for reading
Peterson and Pennington, 2012
GENETICS - PATHOPHSYSIOLOGY
The genetic architecture underlying dyslexia is complex and multifactorial
9 susceptibility genes named DYX1 to DYX9 with various candidate genes
No genome wide association studies till date
Two or more genes contribute to the phenotype
Polygenecity
Same disorder can be caused by multiple origins in different individual
Heterogeneity
Scerri et al, 2010
GENETICS - PATHOPHYSIOLOGY
• Studies of post-mortem dyslexic brains
– cerebrocortical neuronal migration disorders ranging from small heterotopia to focal microgyria
• All the Dyslexia candidate genes play a central role to a signaling network involved in neuronal migration and neurite outgrowth
abnormal neuronal migration
anomalous brain
oscillations
Auditory signal
disturbance
Poor phonological processing
Scerri et al, 2010
ETIOLOGY
• Literary outcomes
• Reward and punishment
• provision of teaching,
• cultural attitudes
• socio-economic
factors
• Underlying Process
• Genetic
• Neuro-Anatomical
Biological Cognitive
BehavioralEnvironm
ental
The overall etiology can be summarized as the interplay of different factors
• Evolution of concept
• Concept and approaches
• Epidemiology
• Pathophysiology
• Assessment and Management
• Prognosis
• Issues Indian Context
• Conclusion
ASSESSMENTAUTHORS NAME CONTENT AREAS REMARKS
Kapur, John, Rozario and Oommen, 1991
NIMHNSIndex for SLD
Level1-preacademic skills 5-7 yrsof ageLevel 2- class1-7
Conjunction with MISICAreas: Attention, reading, spelling, perceptuo-motor, visuo-motorMemory, arithmetic
Validity and reliability definesEnglish and HindiCut off provided
Konanthambigiand shetty, 2008
Scale Developed at special education cell of SNDT women university
Using behavior checklist For teachers for identification
Validity not defined
Yadav and Agrawal, 2008
Learning disability scale
19 questions in 5 areas
Verbal disability, oral attention disability, writing disability, mathematical computation disability, written attention disability
Short scaleEasy administration Validity not known
ASSESSMENTSTUDY BATTERY CONTENT REMARKS
Mehta M and Sagar R, 2003
AIIMS SLD battery
Bender Visuo-Motor Gestalt test
for motor co-ordination
Reading (using NCERT book
text)
Expression - verbal and written
Comprehension
Arithmetic
Non verbal SLD
No cut offQualitativescale
Apart from these Indian scales there are other questionnaire • Diagnostic reading scales• Reading Acquisition Profile in Kannada (RAP-K) in Kannada (Prema1998)• Behavioral checklist for screening the learning disabled (Swarup and
Mehta ,1991)• Wechsler Objective dimension(1993)• Woodcock Johnson 3 achievement(2001)• Wide Range achievement test • Schonell spelling test
ASSESSMENT
Step 1: Gather the history
Step2: Standardized assessment
Step 3: Behavioral Observation during assessment
ASSESSMENT
Step 1: Gather the history
Step2: Standardized assessment
Step 3: Behavioral Observation during assessment
• Developmental • Educational• Emotional and behavioral• Classroom observation of learning behavior
• Attention• Organization • Homework• Test taking behavior
• Social interaction with peers
ASSESSMENT
Step2: Standardized assessment
Step 3: Behavioral Observation during assessment
• Cognitive ability• Malin's Intelligence scale for Indian children• Wechsler Intelligence Scale for children IV• Stanford Binet
• Information processing• Auditory and visual• Memory and executive functioning
• Achievement• Reading• Writing• Mathematics
ASSESSMENT
Step 3: Behavioral Observation during assessment
• Level of anxiety• Fatigue• Handwriting, pencil grip, pressure while writing• Ability to sustain attention during assessment
Integrated approach involving audiologist, ophthalmologist, neurologist, speech therapist, occupational therapist, pediatrician and psychiatrist
SN PROFESSIONAL ROLE ASSESSMENT
1 The Pediatric Neurologist
detailed clinical history and thorough physical examination• exclude medical cause• identify behavioral causes
2 Counsellor • Rule out any environmental deprivation due to poor home or school environment, or any emotional problem due to stress at home or at school
3 Clinical Psychologist
• Conduct the standard intelligence test to determine IQ and rule out intellectual disability
• Assess the learning disability in different areas using Battery of tests
• Assess: Emotion and Behavioral problems the child is facing Comorbidities, Other Psychological issues
• Assess: Neuropsychological deficits
4 The Special Educator
• Further assess and address the issues accordingly
5 Child Psychiatrist
• Rule out diagnosis of other conditions which cause poor school performance, viz., "isolated" ADHD, depression, conduct disorder, and oppositional defiant disorder
MANAGEMENT
SN PROFESSIONALS MANAGEMENT
1 Clinical Psychologists • Psychoeducation• Provide psychotherapy for the
emotional problems, anxiety, behavioral problems, poor self esteem
• Address the neuropsychological problems
2 Psychiatrists • Provide psychotherapy • Medications if required for the
comorbidities
3 Special educators • Major role in providing training and special education as per need of the child
INTERVENTION
Fox et al, 2009
INTERVENTIONS(READING)
• High interest/low vocabulary materials
• Multisensory method
• Programmed reading, Remedial reading drills, Neurological Impress method
Fernald method(whole word approach): 4 steps
• select a word in flash card, trace with fingers, say it loud
• Repeat without tracing
• Repeat without writing
• Learn new word from the last word
Gillingham method(Phonic method):
• One letter in card spoken by teacher
• Repeated by student many times
• Expose card and ask
• Teacher makes sound represented by letter and ask the letter
INTERVENTIONS(WRITING)
• Handwriting practice
• Fading model
– Match upper and lower case
– Make association like p=Flag
• Cover and write method
• Spelling games: blocks, scrabbles
• Multisensory like in reading creating distinct visual image and habit formation through repetition
• Showing student his wrong spelling and correcting it in front
INTERVENTIONS(MATHEMATICS)
• Number work exercises
– Classification: grouping of objects according to their distinguishing character
– Ordering and sequencing on the basis of properties
– One to one correspondence: distributing pencils, matching school bags
• Multiplication addition etc with beads, blocks or straws
• Weave math into daily life
• Evolution of concept
• Concept and approaches
• Epidemiology
• Pathophysiology
• Assessment and Management
• Prognosis
• Issues Indian Context
• Conclusion
PROGNOSIS
National center of learning disabilities, 2014
PROGNOSIS
National center of learning disabilities, 2014
PROBLEMS IN ADULT
• Systemic review
• 33 studies 318 factors extracted and classified in International Classification of functioning disability and health (ICF)
• Adult dyslexic came out with the problems in the domains as :
– Negative feelings and emotions like frustration insecurity, anger, stigmatized, inferiority feeling
– Difficulty in organizing and planning
– Difficulty solving problems
– Difficulty in reading or writing
– Difficulty acquiring and keeping job
– Poor support and negative attitude at work- Fear of demotion
All the domains of life personal , environment , social affected by dyslexia Beer et al, 2014
• Evolution of concept
• Concept and approaches
• Epidemiology
• Pathophysiology
• Assessment and Management
• Prognosis
• Issues Indian Context
• Conclusion
ISSUES INDIAN CONTEXT
Certification of SLD
• No uniform national guidelines for diagnosis and assessment of severity and certification of SLD
Difficulties in creating uniform assessment tools:
• Multiple language spoken in India
• Awareness problems in parents and teacher
• differences in quality of teaching , school environment, student teacher rat
Facilities
• Not recognized as a disability in the PWD Act 1995
• Provision like extra time , change in the subject etc. by CBSE board
• No consensus among the boards
25 item questionnaire regarding knowledge of LD in regular school, pre service and special school teachers • Minimum knowledge in pre
service teacher• 70% supported LD as a
problem.(Saravanabhavan , 2010)
50 parents of LD(semi structured questionnaire)Only 16% aware of cause, 66% felt some kind of education needed and only 11% knew it was a life long disorder(Karangde, 2007)
Abuse of certificates in urban areas • Ambitious parents
• Demand certificates even if children are dull average in intelligence
• Instances where children asked to make deliberate mistakes
• School authorities • Concerned about
results by giving facility of provisions
• Untrained professionals• Training as a business
Mehta, M, 2011
Right of Children to Free and Compulsory
Education Act, 2009 (RTE Act)
Pros
• Makes education for children 6-14 yrs. of age free and compulsory
• No child held back, expelled or required to pass a board examination until completion of class standard VIII
• Preventing the stress, maladjustment or behavioral problems related to detention
Cons
• Late referral of the children to learning Disability clinic
• LD children would be diagnosed late
• Crucial time period for "remedial education" i.e. lost opportunity to overcome Disability will be lost
• Psychological trauma to the child and to the parents
Unni,2012
Right of Children to Free and Compulsory
Education Act, 2009 (RTE Act)
Pros
• Makes education for children 6-14 yr of age free and compulsory
• No child held back, expelled or required to pass a board examination until completion of class standard VIII
• Preventing the stress, maladjustment or behavioral problems related to detention
Cons
• Late referral of the children to learning Disability clinic
• Dyslexic children would be diagnosed late
• crucial time period for "remedial education" will be lost i.e. lost opportunity to overcome Disability
• Psychological trauma to the child and to the parents
Amendment that mandates that children who are getting poor marks/grades, irrespective of their class standard, are referred to a Learning Disability clinic to undergo an assessment of their academic difficulties
Unni,2012
PATHWAYS TO CARE
• N=50 cases of specific learning disability
• 8-16 yrs
• Pathways to Care Instrument devised by Goldberg and Huxley
Mean time 1st care 1.08 yrs
Mean time tertiary care 3.39 yrs
PresentationcomorbidityPoor academics
14%64%
Chakraborty et al, 2014
TIME LAG IN DIAGNOSIS
• 50 children diagnosed with SLD and/or ADHD
• Hospital based
• Average age of diagnosis: 11.36
• Average age at which children’s symptoms noticed: 5.55yrs
• Delay: 6 yrs.
• 30% already had class retention
• 40% had aggressive or withdrawn behavior
• Significant lag in detection and diagnosis• Children with SLD and co-occurring ADHD need to be
identified at an early age to prevent poor school performance and behavioral problems
Karande et al , 2007
FACTORS FOR IDENTIFICATION
• Educational longitudinal study
• N=16000 from 750 schools
Positive predictors of identification
• Language minorities i.e. foreign language as first language
• The students enrolled in ELS
• Male
• Non white population
Negative predictors of identification
• Student enrolled in US schools after primary education
Shifrer et al, 2010
FACTORS FOR RECOGNITION
Difficulties in India
• Multi language and multicultural setting
• 18 different orthographic forms of language
• 3 language system in education State, Hindi and English
• Lack of tools of assessment in different language
S Rama, 2000
• Evolution of concept
• Concept and approaches
• Epidemiology
• Pathophysiology
• Assessment and Management
• Prognosis
• Issues Indian Context
• Conclusion
CONCLUSION AND WAY FOREWARD• There has been a progressive shift in the understanding of learning
disability as a disorder and last decade has seen good number of research in this field
• There have been criticism in the definitional issues from past that continue to happen in present
• Children with learning disability face problems in multiple facets of life (with or without comorbidities) even when they become adult –early intervention warranted
• Despite a lot of research the it hasn’t been possible to formulate causal mechanism – role of neurobiology and genetics present but exact mechanism not known
CONCLUSION AND WAY FOREWARD
• In Indian prospective research are limited even to determine the overall prevalence
• Lack of tools in different language and lack of grading system has made assessment difficult
• Legislative support for the dyslexic children throughout the country via proper policy and facilities is warranted
• Further research in this field warranted