- 04/July/2023
Unlocking the Key to Understanding Learning Disabilities in Children: The Role of Developmental Paediatrics
Specific Learning Disorder
While every kid has trouble with homework from time to time, if a certain area of learning is consistently problematic, like reading, writing maths, it might indicate a learning disorder. Parents may worry about child’s future or how they will make it through school. Child may be labelled as slow , or lazy
Specific learning disorder (SLD) is one of the most common neurodevelopmental disorders affecting 5%–10% of children worldwide with severe academic and psychosocial consequences. It is a common cause of scholastic backwardness and the reported prevalence in India is 1.6-15%. Boys are 2-3 times more affected in comparison to girls.Child struggles to acquire academic skills such as reading, writing, and calculations in spite of having normal intelligence and adequate opportunity to study. The affected academic skills are substantially below those expected for the age, and cause significant interference with academic or occupational performanceHowever, apart from academic skills, the child is at par with his peers.
Children may perform poorly in school due to other causeslike
Neurological diseases with low IQ and developmental delay.
Nonneurological diseases including heart diseases, recurrent pneumonias, and poor nutrition.
Vision and hearing problems.
Neurodevelopmental issues: Attention deficit hyperactivity disorder (ADHD), autism.
Poor schooling, school absenteeism, bullying, and over pampering.
Environmental issues such as too much noise, television, and other social media usage.
Emotional problems such as sexual abuse, neglect, and parental problems.
Children are diagnosed as SLD either because of their below average scholastic performance, or due to secondary psychological effects of difficulty in learning. As these children have normal IQ and they lack only in a narrow range of skills, they are not easily identified initially.No Detention Policy (NDP) in school also leads to delayed identification of learning problems
Early identification
Parents and teachers should be aware of different symptoms of specific learning disability
Preschoolers-A preschool child with SLD often has several related early signs which helps in early identification: such as language delay,slow acquisition of vocabulary, pronunciations problems, struggles to learn the connection between letters and sounds, poor hand skills like using scissors,drawing and writing, trouble in learningnumbers, alphabets,colours,shapes, etc. They may be very restless ,fidgety and easily distracted
Primary school
Trouble learning the connection between letters and sounds,
Unable to blend sounds to make words,
confuses basic words when reading.
Letter reversals (b,d),inversions(m,w),jumbled letters (felt, left etc)
trouble learning basic math concepts, difficulty telling time and remembering sequences.
Middle & high school
Child’s academic performance deteriorate as academic load increases,
Relies on rote memorisation to compensate poor understanding of concepts
Child who seems to be intelligent but doing poorly in academics
Child Good in everything else except studies
Unexplained behavioural problems
IAP recommends screening of all children at the age of 7 years for LD in the pediatric clinic (2-3 years after school exposure)
Types of learning difficulties
Reading disability (also known as dyslexia) is the most common LD, accounting for at least 80% of all LDs. Difficulties includes slow reading, reading word by word, constantly losing place, missing out lines or reading the same line again.
Dyslexia present initially in primary school years as reading difficulty due to problems in letter-sound relationships, (phonological processing). Child may try to sound out the individual elements of word(decoding words), but is often unable to synthesize it into the correct word . Reading comprehension problems occur when there is an inability to grasp the meaning of words, phrases, and paragraphs. Problems in reading comprehension usually present later as the effort is more on learning to read than understanding the content.. - these can be identified by low overall reading achievement, or by low reading ability, relative to overall intelligence
Dyscalculia is generally characterized by difficulty in learning or understanding mathematical facts. A student with arithmetic disorder might have difficulty with number sense, in understanding arithmetic calculations and operations, like operation signs, and number “facts” (like 5+5=10 or 5×5=25). multiple step calculations such as long division& word problems and transposing numbers accurately on paper or on to a calculator
Dysgraphia is generally characterized by distorted writing despite thorough instruction.
A student with dysgraphia exhibits inconsistent and illegible writing, mixing upper and lowercase letters ,‘difficulty in written expression’ which indicates problem in spelling , grammar or punctuation and clarity or organization of written expressions., and difficulty in writing on a line and inside margins. They might have fine motor difficulties such as trouble holding the pencil correctly.(too light or too heavy pencil strokes) and avoids/dislike writing
It is important to remember that many children will have more than one type of SLD
Risk factors
- Prematurity and low birth weight increases the risk for SLD
- Genetic &environmental factors -LD has a strong genetic component. family history of learning difficulties and poor educational level of parents indicate the combined role of genetic and environmental factors for SLD in their children
- Marked inattention in early years may predict academic difficulties later
Comorbidities
Children with attention deficit hyperactivity disorder (ADHD), ASD, communication disorders, and developmental coordination disorders can have associated learning disorder.Comorbid LD account for some of the academic underachievement in ADHD children and children with LD can have secondary attention deficits and hence all children with LD should have preliminary screening for ADHD.Mental health issues like Anxiety, depression, and disruptive mood disorders are common
Many of these children will face bulling, and peer rejection in school. They may have poor self-esteem.They may try to avoid school, and become school drop outs
Diagnosis
LD can only be diagnosed after children start formal schooling at 5 years. It can be diagnosed any time afterwards provided the onset is in the early years. Vision and hearing problems should be ruled out before labelling the child as SLD.Formal IQ should be done to assess the intellectual level of the childand a severe discrepancy between scholastic and IQ scores should also be included in the diagnosis.
Assessment
The class teachers must be trained to identify children with possible SLD. Children at risk for SLD include those with poor academic performance, reading difficulty, poor handwriting, difficulty in basic mathematical facts and poor memory.Teachers must be educated about these red flag signs of SLD and should refer such children early to paediatrician and psychologist for detailed evaluation.
A comprehensive assessment would include both screening and standardized confirmatory tests by the pediatrician and clinical psychologist
For the diagnosis of SLD, the clinical psychologist may test the child on some standardized tests for IQ (to establish average or above average IQ) and psychoeducational tests for establishing patterns of learning difficulties in reading, writing, Mathematics,. consistent with a standardized diagnosis of SLD. If the pediatrician has noted any red flags in terms of behavioral or emotional concerns, child may be assessed by the clinical psychologist. The clinical psychologist will make a detailed report of such assessments for the pediatrician’s perusal.
Intervention
is by multidisciplinary team consisting of developmental pediatrician, pediatric Neurologist, clinical psychologist, special educator and occupational therapist.
Remedial education (i.e., educational assessment and individualized education program), Remedial education includes educational assessment of the child to identify the child’s learning style, strengths and weaknesses in academic skills and developing an individualized education program (IEP) for each child ,setting short-term and long term goals. Interventions should focus on developing and strengthening language and basic skills of reading, writing and arithmetic. Intervention sessions for a duration of 45minutes (i.e., twice- or thrice-weekly is offered in school or outside regular school hours by special educators.
Special educator provides direct one-on-one teaching to thechild. Remedial intervention programs focus on different strategies to help the child to internalize and understand the required academic skill. Though there are a number of remedial intervention programs that can be used, it is vital to design one that is appropriate to your child. Multisensory techniques for teaching maths and life science will be useful
Reading
Teaching children letter sound relationis essential for reading,Phonemic awareness stresses on understanding each letter separately, stressing on each letter, remediation of letter sound knowledge, stressing on word recognition, and reading books. Remedial education should begin early when the child is in primary school.Reading programs through library activities, for example, storytelling and individualized remedial reading sessions are essential.Instruction in vocabulary, background knowledge, and comprehension strategies are also given.Repeated oral reading practice may help in improving fluency. Reading comprehension skills are linked to larger language comprehension skills and needs to be developed.
Writing
is more complex skill than reading and it may co-occur with reading disorder or independently.For improving the pencil grip,hand exercises such as working with clay, beading etc are advised. Let children do a lot of tracing, copying coloring and writing on dotted lines to improve hand writing. To improve spelling, phonics instruction and teachingof letter writing is used .To master phonics, educational games and activities are useful. To improve the written expression like essay writing, which involve planning, organizing, reviewing and editing skills, practice using concept maps and different aids and strategies are employed
Mathematics
Number sense refers to having mental representation of quantity (i.e., ability to estimate and judge magnitude)andis a prerequisite for math which should be taught..Counting strategies, number facts and rules for addition, subtraction, multiplication and division must be taught directly and explicitly Reading difficulties can aggravate difficulties in doing word problems
Multi Sensory Teaching
‘VAKT’ (Visual-Auditory-Kinesthetic-Tactile) model of multisensory teaching uses all the four major learning pathways implemented in the cognitive learning process which not only helps to enhance the memory, but also helps uplift the emotional, physical and societal dimensions.
Teachers can use multi-media presentations for performing their task. Using multimedia presentations for letters, words or rhymes and enacting them out during the session along with the whole class.
In addition ensuring that children are allowed to “think” for themselves, to develop higher cognitive functioning is vital.
These interventions help the children ways and means to complete school successfully so they can grow into confident, motivated individuals with their self esteem intact.
Provisions
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. Accommodations and modifications of curriculum are essential for this.
Accommodations would include classroom alterations such as seating the child in front, alterations in class work and homework such as individualizing assignments, regarding length, number, due date, topic and alterations in examinations such as multiple choice questions, oral examinations, reading of question paper, allowance for spelling errors
National educational boards ICSE & CBSE have granted the following concessions to children with LD in the exams.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
SLD is a lifelong condition, children do not grow out of SLD. However, their reading, writing, and mathematics abilities will improve with the help of various therapies
There are many famous personalities like Alber Einstein,, Leonardo Daviciwith SLD who overcame their difficulties..
Children with SLD are as smart as other children and can be successful. They just need to be taught in ways that are tailored to their unique learning style.students with LD can be poor in academic intelligence but may be better in other domains, they can choose from variety of carrier options based on their aptitude like music, art ,computer ,design, sports, hospitality etc
It's important to understand that learning disabilities are not a reflection of a child's intelligence or potential. With the right support and accommodations, children with learning disabilities can achieve great things and lead fulfilling lives. The expertise of developmental paediatricians at Ananthapuri Hospitals, combined with the collaborative efforts of parents, educators, and therapists, ensures that children receive the individualized care they need to navigate their learning journey successfully. Schedule your appointment today by calling +91 9400332777 or visiting our hospital in Thiruvananthapuram at Chacka, NH Bypass.
Article By
DR SAILAJA SREEJITH
MBBS, DCH, Fellowship in Developmental and Behavioral Pediatrics(IAP)
SENIOR CONSULTANT - DEVELOPMENTAL PAEDIATRICIAN