L
earning Disability (LD) in children is a
well-recognized developmental disorder with profound academic and
psychosocial consequences. Due to the complex nature of LD and the
multiple disadvantages posed to the child due to LD, a multidisciplinary
approach towards intervention is warranted. Given the paucity of
published standardized treatment approaches for use in India, consensus
guidelines for management of LD are needed.
The meeting on formulation of national consensus
guidelines on neurodevelopmental disorders was organized by Indian
Academy of Pediatrics in Mumbai, on 18
th
and 19th December, 2015. The
invited experts included Pediatricians, Developmental pediatricians,
Pediatric neurologists, Psychiatrists, Remedial educators and Clinical
psychologists. The participants framed guidelines after extensive
discussions. Thereafter, a committee was established to review and
finalize the points discussed in the meeting. The following sections
include the points of consensus on evaluation and management of LD.
Terminology: The term ‘Learning Disability’ (LD)
is used synonymously with Specific Learning Disability and Specific
Learning Disorder, the latter used by the fifth edition of Diagnostic
and Statistical Manual of Mental Disorders (DSM-5) [1]. However, in some
countries, the term refers to intellectual disability (formerly called
‘mental retardation) [2,3].
Definition: LDs are a heterogeneous group of
disorders where the individual unexpectedly fails to competently
acquire, retrieve and use information. The academic achievement is lower
than expected, based on the child’s overall intelligence [2-4]. LD has
been defined as a neurodevelopmental disorder of biological origin
manifesting in learning difficulties and problems in acquiring academic
skills, which are markedly below age level. LD manifests during early
school years and it is not attributed to intellectual disabilities, or
neurological or motor disorders. The difficulties should last for at
least six months, to warrant a diagnosis [1].
The recommendations have been drafted for an
age-range, based on current evidence. The diagnostic tool developed by
the National Institute of Mental Health and Neurosciences (NIMHANS) for
children with LD, is one of the recommended tools in India [5]. It
includes two levels: Level-1 for children 5-7 years of age and Level-2
for children 8-12 years of age [5]. Hence, the recommendations pertain
to children 5 years and above.
Prevalence: Approximately 5% of all students in
public schools in the United States are identified as having LD [4];
while another study in US reported that 7% of children 3-17 years of age
had LD [6]. The reported prevalence in India ranges from 1.6%-15%,
varying based on age-range, survey method, tool used, and region of the
country [7-10]. A cross-sectional study conducted in Chandigarh (n
= 3600, grade 3 and 4 students) reported 3.08% of children with a
diagnosis of LD [8]. Another study using informal assessment, conducted
in five schools in Jaipur (n=1156, children 6-13 years of age)
reported 12.8% with LD (21.6%, 15.5% and 22.3% of children with
dyslexia, dyscalculia and dysgraphia, respectively) [9].
Types of Learning Disabilities
Dyslexia: Dyslexia or reading disability is a
specific type of reading disorder caused by deficits in phonologic
processing. These deficits are unexpected in relation to the student’s
overall intelligence and persist even after receiving appropriate
(general educational) instruction. Dyslexia presents initially with
problems in letter-sound relationships (i.e., decoding words and
reading fluently in kindergarten or grade one). Problems in reading
comprehension usually present in the latter part of the primary school
years, when the focus is on reading to learn rather than learning to
read - these can be identified by low overall reading achievement, or by
low reading ability, relative to overall intelligence.
Dysgraphia: Dysgraphia or writing disabilities
are caused by a range of neurodevelopmental weaknesses, including
problems with handwriting (fine motor or grapho-motor) and
visual-spatial perception. Children present with difficulties in copying
efficiently from the board; may show excessive grammar and punctuation
errors; may produce overtly simple written text and/or produce
disorganized text that is difficult to follow. In contrast, problems
exclusively in spelling (also called ‘encoding’, which is the ability to
use letter-sound relationships effectively) in absence of problems in
written expression is more indicative of a phonologic processing deficit
(i.e., dyslexia), than a dysgraphia. Other problems include those
in grammar and syntax as well as formulating, expressing and organizing
ideas in writing.
Dyscalculia: Dyscalculia or mathematical
disabilities may include problems with number sense, problems retrieving
math facts (arithmetic combinations or calculations), difficulty with
the language of math (correctly reading and understanding numbers and
symbols), word problems in math (correctly reading and understanding the
text of word problems) and the visual-spatial and organizational demands
of math. Students may reverse numbers or make errors while
reading them aloud. These problems are usually seen in conjunction with
disabilities in reading or written expression. Math functions depend
upon the ability of the student to understand words associated with
arithmetic operations and word problems. Dyslexia can aggravate
difficulties in acquiring math skills.
Co-morbid Conditions
These include Attention-deficit Hyperactivity
Disorder (i.e., inattention, hyperactivity, impulsivity, having
difficulty sustaining focus, being disorganized); Autism Spectrum
Disorder (i.e., impairment in reciprocal social communication and
social interaction; restricted repetitive patterns of behavior,
interests or activities); Communication Disorders (i.e., deficits
in language, speech and communication) and Developmental Coordination
Disorders (i.e., impairment predominantly in gross and fine motor
skills including handwriting skills, pedaling, buttoning shirts,
completing puzzles, using zippers, playing ball games, etc.).
Recommendations
Diagnosis
The diagnosis of LD is made primarily by history.
Diagnostic criteria and differential diagnoses (e.g. normal
variations in academic achievement, ADHD, Intellectual disability,
Learning disorders due to sensory or neurological impairments) have been
provided in the DSM-5 [1]. These conditions can be differentiated by
history, examination, laboratory tests (e.g. blood lead level),
hearing and vision assessment, specialized screening/referral.
Psychometric tests help to confirm the presence of LD
and identify targets for intervention. An appropriate assessment for LD
includes information from student’s educational history, a description
of classroom observations and standardized psychometric measures. LD can
only be diagnosed after formal education starts, but can be diagnosed at
any point afterward in children, adolescents, or adults, provided there
is evidence of onset during the years of formal schooling. No single
data source is sufficient for diagnosis. A mandatory vision and hearing
assessment should be part of the protocol. Investigations for lead
toxicity may be conducted, if suspected.
Assessments
Scales to diagnose LD take longer time to administer,
which necessitates screening to identify ‘at-risk’ children. It is
important to identify these children early, after school starts, for
early intervention. Studies conducted in India to measure prevalence of
LD have used screening questionnaires such as Specific Learning
Disability-Screening Questionnaire (SLD-SQ) [8] or designed screening
tools for class teachers to identify LD [10]. Pediatricians could use
the SLD-SQ or focus on certain pointers in the latter to identify
‘at-risk’ children, in order to refer them for thorough evaluation by a
developmental paediatrician. The pointers include: unexplainable absence
from school, below average academic performance, poor writing ability,
problems in reading ability, poor mathematical competence and problems
in recall. Concerns in two or more of these areas, should warrant a
referral [10].
The language availability, cost, diagnostic
performance and time taken to administer a range of tests more suitable
for Indian children, especially those who are first-generation English
learners, have been summarized in Table I [5,11-15].
TABLE I Assessments for Learning Disability
Name of the |
Age group/ |
Cost |
Note on diag- |
Time taken |
Available languages
|
test/battery |
grade |
|
nostic performance |
|
|
NIMHANS
|
Level I: 5-7 yr Level II: 8-12 yr |
Freely available |
Test-re-test reliability: 0.53 (p< 0.001) |
Variable (battery of tests)
|
English, Hindi, Kannada
English, Hindi |
GLAD/font> |
6 yrs or older |
FFreely available |
Test- re-test reliability: 0.68 for Grade IV to 0.99 for grade III;
Criterion validity: 0.74 to 0.89 |
Variable (curriculumbased)
|
|
|
|
|
|
|
|
BKTfont> |
3-22 yrs |
INR 2000*
|
IQs correlate highly with measures on Stanford-Binet
Intelligence Scales |
2 hours |
English; can be used with children not adequately exposed to
English |
WJ-III achievement |
2 yrs and above |
$2207* |
Reliability: 0.81-0.94 |
60-70 minutes |
English |
*i*in January 2017; GLAD: Grade Level Assessment Device; BKT:
Binet-Kamat test; NIMHANS: National Institute of Mental Health
and Neurosciences. |
NIMHANS index to assess children with LD [5]. The
index comprises of the following tests: (a attention test (number
cancellation); (b) visual-motor skills (Bender-Gestalt
test and developmental test of visual-motor integration); (c)
auditory and visual processing (discrimination and memory); (d)
reading, writing, spelling and comprehension tests; (e) speech
and language assessments including auditory behaviour (receptive
language) and verbal expression; and (f) arithmetic tests
(addition, subtraction, multiplication and division).
The Rehabilitation Council of India (RCI) recommends
informal assessment (i.e., parental interviewing after consent;
gathering information from teacher/school; reviewing student’s
workbooks; and interviewing the child) and formal testing (i.e.,
criterion and norm-referenced tests). Tests for LD have two components:
(a) testing for potential performance discrepancy – where a
two-year discrepancy between potential and performance is an indicator
of possible LD and, (b) testing of processing abilities.
One or more tests have to be administered based on
the child’s age and cognitive ability. The range of tests that can be
administered are as follows:
Intellectual assessment: Woodcock Johnson Tests
of Cognitive Ability (3
rd
edition; age two and above) or Malin’s Intelligence Scale for Indian
Children (for children 6 years and above), which is the Indian
adaptation of Wechsler Intelligence Scale for Children (WISC);
Achievement: Woodcock Johnson III – tests of
Achievement for children; Nelson Denny Reading Test for high school and
college students;
Cognitive Processing Abilities:
Woodcock Johnson
Psycho-Educational Battery Revised (Part 1 – tests of cognitive
ability), Weschler Memory Scales Revised (age 16 years and above),
Benton Visual Retention Test (age 8 years and above), Beery Visual-Motor
Integration Test (age 2 years and above), Raven Colored Progressive
Matrices (age 5 years and above) Rey Auditory-Verbal Learning Test (age
³16 years),
Bender Visual Motor Gestalt Test (age 4 years and above) and NIMHANS
Index (Level I: 5-7 years and Level II: 8-12 years).
Assessment of intelligence is essential to exclude
intellectual disability as a primary cause of difficulties in learning.
In a multi-linguistic country like India, it is
important to develop scales to diagnose LD in non-English speaking
students. As mentioned above, RCI has advised informal assessment for
these students, in absence of standardized scales. Moreover, the Grade
Level Assessment Device (GLAD) for children with learning problems in
schools has been developed by the National Institute for the Mentally
Handicapped (NIMH) [11].
It is essential to exclude other impairments as the
primary cause of learning difficulties. Such impairments include low
intellectual quotient; sensory deficits (visual and/ or hearing
impairment); physical impairments; history of multiple education
settings; poor educational background or lack of prior learning; and
cultural differences contributing to lack of experience with the English
language (e.g., first-generation English learners). However, LD
may co-exist with the above.
LD being a language-based disorder, it is imperative
that tests for both receptive and expressive language be included in the
comprehensive assessment. Other procedures include curriculum-based
assessment; dynamic assessment; learning styles assessment and
outcome-based assessment.
Intervention Approach
A basic intervention approach should focus on: a)
interpretation of evaluation reports; b) description of specific skills
that may be delayed (e.g., phoneme awareness and phonics, reading
comprehension, spelling instruction, number sense, and organizational
skills), and c) identification of co-morbidities.
The intervention should be inter-disciplinary and
individualized to each child. Required services include: developmental
pediatrics evaluation; neurological evaluation; ophthalmology and
audiology evaluation; clinical psychology assessment; occupational
therapy (e.g., handwriting, attention, hyperactivity,
visual-motor coordination), remedial education (i.e.,i.e.,
educational
assessment and individualized education program), counseling for family,
and career-counselling.
Remedial education includes educational assessment of
the child for strengths and weaknesses in academic skills; development
of an individualized education program (IEP) for each child having
short-term and long-term goals, and monitoring the child’s progress.
Intervention sessions (i.e., twice- or thrice-weekly) could
typically last for 45 minutes and continue for few years. Sessions could
be offered in school or outside regular school hours. Parents need to be
trained to adopt the strategies at home. Specific strategies include: (a)
Review information about previous lesson on the topic before beginning
the current lesson; (b) Clearly state what the student is
expected to learn during the current lesson; (c) Describe how the
student is expected to behave during the lesson e.g., tell the
child not to talk with peers if the assigned task is found to be
difficult, but to raise his/ her hands to get the teacher’s attention; (d)
State all materials that the child will need during the lesson
e.g.,
specify that the child needs crayons, scissors and coloured paper
for an art project rather than leaving the child to figure out the use
of materials; (d Psycho-educational interventions (e.g.,
seating the child near the teacher to minimize classroom distractions),
and (e) Assigning a specific teacher to review daily assignments.
Intervention Strategies
Phoneme awareness-Reading: During these sessions
the child with dyslexia undergoes systematic and highly structured
training exercises to learn that words can be segmented into smaller
units of sound (‘phoneme awareness’). DurinDuring these sessions, the
remedial teacher explicitly and directly teaches the following tasks: (i)
Phoneme segmentation: e.g, what sounds do you hear
in the word pot? What is the last sound in the word tap?; (ii)
Phoneme deletion: e.g., What word would be left if
the /m/sound was taken away from mat?; (iii) Phoneme matching:
e.g., Do ‘pen’ and ‘pipe’ start with the same sound?; (iv)
Phoneme counting: How many sounds do you hear in the word
‘take’?; (v) Phoneme substitution: What word would you have if
you changed the /p/ in pot to /h/?; (vi) Blending: What
word would you have if you put these sounds together? /f/ /a/ /t/; (vii)
Rhyming: Tell me as many words as you can that rhyme with the
word eat.
Reading-Phonics instruction:
Phonics instruction
begins only after phonemic awareness gets developed. The child is taught
that these sounds ("phonemes") are linked with specific letters and
letter patterns ("phonics"). The goal of teaching phonics is to link the
individual sounds to letters, and to make that process fluent and
automatic for both reading and spelling. In other words, phonics teaches
students symbol-to-sound and sound-to-symbol linkages. SpellSpellings
are taught through ‘phonics-based teaching’ using colour-coded
segmentation (e.g., bot/tle), word formation games and sight-word
identification. However, the English language has words like ‘any’,
‘because’, ‘island’, ‘enough’, etc. which are impossible to spell from
the sounds of their letters. These tricky words can be learned via
mnemonics’. However, even after years of adequate remedial
education, subtle deficiencies in reading, writing, and mathematical
abilities do persist in many children. To develop reading fluency and
automaticity should be a critical intervention goal for older children.
Basic principles – writing skills:
All of the components of writing need to be considered to
create an intervention plan for addressing the components that are most
affected. Lower-order writing skills consist of printing/handwriting
(transcription skills) and spelling skills (a phonics-based skill that
requires sound-symbol relationships). Ultimately, the student should
have memorized certain number of high-frequency words and spell them
automatically (i.e.,
writing fluency), without which higher-order skills are more difficult
to master. Higher-order writing skills require the ability to write
sentences (e.g., understand language conventions related to
punctuation, grammar, etc.) and produce a composition. Writing
instruction involves drill and practice (explicit or direct instruction)
of lower-order skills (transcription, spelling and writing fluency) in
the service of higher-order skills (writing sentences and compositions).
Direct instruction is required for the student to achieve accurate
letter formation and fluency in writing, spelling, punctuation and
grammar. Improvements in these lower-order skills can improve higher
order performance. Specific types of instruction (e.g., strategy
instruction) can be used to improve performance in higher order writing
skills.
Basic principles – Mathematics: Competence in
mathematics depends upon mastery of lower-order skills which are then
used in the service of higher order skills. In Mathematical disorder,
primary deficits occur in number sense and math facts (arithmetic
combinations or calculations). Performance in higher-order math skills
also depends upon math fluency i.e., the fluent application of
number sense and math facts. Students with this disorder also have
difficulty solving word problems. This can be due to problems in number
sense and calculation skills or a coexistent reading or language
disability. Thus, effective remediation for reading and writing
disability has to be primarily worked upon. Finally, visual-spatial and
organizational problems can interfere with success in mathematics, which
requires occupational therapy intervention.
Specific areas where intervention should focus have
been described below:
Number sense:
Number sense refers to having mental representation of quantity (i.e., ability to estimate and
judge magnitude). It is an early-emerging skill that can fail to develop
in students with Mathematical Disorder. Number sense is a prerequisite
for math, and is a teachable skill. It can be compared to phonemic
awareness, which is a prerequisite for reading (decoding), and is also a
teachable skill. Number sense can be taught by (a) practicing
identification or estimation of quantity (i.e., less and more); (b)
1:1 correspondence (e.g., correlating the number of coins being
dropped into a box with the sound made by each of the coins, as it
drops); (c) serial ordering (numbers are always counted in the
same order); (d) "counting on" (i.e., identifying changes
in quantity by adding up from a smaller quantity to create a larger
quantity); (e) showing the link between addition and subtraction
while using objects; (f) using more than one type of visual
representation for numbers (e.g. both horizontal and vertical
number lines); and (g) oth) other visual representations that show
differences in size, volume, etc.
Mathematical facts or calculation skills:
Number sense is required to understand how to add, subtract, multiply,
and divide numbers. However, these skills are also acquired by learning
the rules for addition, subtraction, multiplication, and division. The
strategies used include efficient and effective counting-strategy use,
mathematic fluency, mathematic vocabulary and word problems,
visual-spatial skills in mathematics and organization and planning in
mathematics. They are detailed in Web Box 1.
Provisions and Advocacy
Advocacy of the rights of children with LD to achieve
optimal potential via provisions is a necessity. Pediatricians as
trustees and custodians of children are the strongest voices that
children have [16-18].
Presently, only few state governments (Maharashtra,
Karnataka, Tamil Nadu, Kerala, Goa and Gujarat) and the National
educational boards that conduct the Indian Certificate of Secondary
Education and the Central Board of Secondary Education examinations have
formally granted the benefit of availing the necessary provisions to
children with LD [19]. Due to the central nervous system’s higher
plasticity in early years, remedial education should begin early when
the child is in primary school [16-18].
The cornerstone of treatment of LD is thorough
comprehensive evaluation and outcome-based, documented multidisciplinary
intervention. Screening of all children at the age of 7 years for LD in
the pediatric clinic will be highly beneficial (2-3 years after school
exposure). No Detention Policy (NDP) leads to delayed identification of
learning problems, and needs to be seriously reviewed. Concept of
multiple intelligence needs to be highlighted i.e., students with
LD can be poor in academic intelligence but may be better in other
domains. Role of National Institute of Open Schooling is pertinent for
children with LD in India [20].
LD lowers the scores of a student’s performance and
provisions are intended to function as a corrective lens, which will
deflect the distorted array of observed scores back to where they ought
to be. These provisions aim to ‘level the playing field’ for these
students as their academic performance would now be matching with their
intellectual potential [21-25].
Concessions for students with LD (all sub-types)
include: (a) One hour or 25% extra time in public exams; (b)
No mark reduction for grammar and spelling mistakes; (c) Use of
calculator in Maths exam; (d) Exemption from writing one language
exam; (e) Use of scribe or typing answers on a computer; and (f)
20% grace marks [21-25].
In terms of inclusion, the following policy-level
changes are conducive for children with LD: (a) Government of
India launched the Sarva Shiksha Abhiyan in 2001 (‘Education for
All’) that aims to provide useful and relevant education to all
children, including children with disabilities in the mainstream
(‘inclusive education’) [26]; (b) Right of Children to Free and
Compulsory Education 2009 (RTE Act) stresses on free and compulsory
education for children 6 to 14 years of age, including children with
special needs, and research has also looked at the challenges in its
execution [27]; and (c)
Rashtriya Bal Swasthya Karyakram
(RBSK) focuses on early detection and intervention of disease,
disabilities, deficiencies and developmental problems [28].
Previously, Learning Disability was not included in
the Persons with Disability Act (PWD, 1995). The recent bill (Rights of
Persons with Disability Bill 2011 and passed as an Act in 2016) has
included LD and recognized it as a disability [25, 29].
Contributors: All authors have contributed,
designed and approved the manuscript.
Funding: None; Competing interest: None
stated.
ANNEXURE I
ParticParticipants of the National
Consultative Meet for Development of IAP National Consensus Guidelines
on Neuro Developmental Disorders.
Convener: Dr Samir Dalwai, Mumbai
Experts (In alphabetical
order): Abraham Paul, Cochin; Anjan Bhattacharya, Mumbai; Anuradha
Sovani, Mumbai; Bakul Parekh, Mumbai; Chhaya Prasad, Chandigarh; Deepti
Kanade, Mumbai; Kate Currawalla, Mumbai; Kersi Chavda, Mumbai; Madhuri
Kulkarni, Mumbai; Monica Juneja, New Delhi; Monidipa Banerjee, Kolkata;
Mamta Muranjan, Mumbai; Nandini Mundkar, Bangalore; Neeta Naik, Mumbai;
P Hanumantha Rao, Telangana; Pravin J Mehta, Mumbai; SS Kamath, Cochin;
Samir Dalwai, Mumbai; Sandhya Kulkarni, Mumbai; Shabina Ahmed, Assam; S
Sitaraman, Jaipur; Sohini Chatterjee, Mumbai; Uday Bodhankar, Nagpur; V
Sivaprakasan, Tamil Nadu; Veena Kalra, New Delhi; Vrajesh Udani, Mumbai;
Zafar Meenai, Bhopal.
Rapporteur: Leena Deshpande,
Mumbai; Leena Shrivastava, Pune; Ameya Bondre, Mumbai.
Invited but could not attend the meeting:
MKC Nair, Thrissur; Pratibha Singhi, Chandigarh; Jeeson Unni, Cochin;
Manoj Bhatvadekar, Mumbai.
Key Messages
• Intervention approach should focus on
interpretation of evaluation reports, description of specific skills
that may be delayed and identification of co-morbidities.
• It is essential to have an inter-disciplinary
approach involving different specialities; regular and concise
documentation facilitates the process.
• The intervention should be inter-disciplinary
and individualized to each child.
• Remedial education includes assessment of the child’s academic
strengths and weaknesses and development of an individual education
program (IEP) having short-term and long-term goals and monitoring
of the child’s progress.
|
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