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

2
(No Transcript)
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 (gt60 disability)
• Hearing handicap (gt 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 (Turners)
• 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
  Heschls 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
Year Total SpLD SL MR
1997 159 69 18 8
1998 296 200 65 8
1999 358 174 69 14
2000 522 226 105 33
2001 475 171 86 24
2002 479 216 43 18
2003 896 540 142 47
2004 966 699 98 18
2005 976 624 64 15
25
At time of diagnosis

• Each childs 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 lt 0.0001
• Children who availed exemption of 2nd language or
  opted for lower grade mathematics scored better
  marks
• (P lt 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