Henal Shah|John K. Vijay Sagar|Mansi Somaiya|Jitendra Nagpal
Clinical practice guidelines on assessment and management of specific learning disorders
National Institute of Mental Health and Neurosciences|Institute of Mental Health|National Institute of Mental Health and Neurosciences|Institute of Mental Health|National Institute of Mental Health and Neurosciences|Institute of Mental Health|National Institute of Mental Health and Neurosciences|Institute of Mental Health
introduction specific learning disorder sld one common neurodevelopmental disorders affecting 310 children although many definitions proposed common consensus diagnostic criteria definition sld nosology 1960s ld emerged category mentioned samuel kirk defined dyslexia kind learning disability defined ld unexpected difficulty learning one one instrumental school abilities per kirk ld process issue affect language academic performance people ages caused emotional disturbance behavioral disturbance cerebral dysfunction1 bateman landmark observation mentioned learning disorders significant discrepancy estimated intellectual potential actual level performance without neurological dysfunction secondary mental retardation educational cultural deprivation severe emotional disturbance sensory loss2 curiosity awareness progressed various definitions proposed across world two worldwide international diagnostic classificationsinternational classification diseases icd 10 diagnostic statistical manual mental disorders dsm 5th edition34 difference two outlined table 1table 1 differences criteria diagnosis specific learning disorder diagnostic statistical manual mental disorder 5 international classification diseases 10the icd 10 refers specific developmental disorders scholastic skills conceptually disorders disturbance normal pattern skill acquisition simply consequence lack neither opportunity learn acquired brain trauma disease abnormalities cognitive processing derive biological dysfunction clinically significant degree impairment specified scholastic skill severity judged scholastic terms developmental precursors scholastic difficulties preceded developmental delays deviance often speech language preschool years qualitative abnormalities response scholastic difficulties rapidly readily remit increased help homeschool impairment must specific solely explained mental retardationlesser impairments general intelligence impairment must developmental early years schooling acquired later educational process impairments characterized specific reading disorder characterized specific significant impairment developmental reading skills accounted mental age visual acuity problems inadequate schooling childs reading performance significantly level expected based age general intelligence school placement performance best assessed means individually administered standardized test reading accuracy reading comprehension early stagesdifficulty reciting alphabets giving correct names letters giving simple rhymes words analyzing categorizing despite normal auditory acuity later stages errors oral reading skills omissions substitutions distortions additions words parts words slow reading rate false starts long hesitations loss place text inaccurate phrasing reversals words sentences letters within words deficits reading comprehension inability recall facts read inability draw conclusions inferences material read use general knowledge background information rather information story answer questions story read specific spelling disorder characterized specific significant impairment developmental spelling skills absence history specific reading disorder solely accounted low mental age visual acuity problems inadequate schooling childs spelling performance significantly level expected based age general intelligence school placement performance best assessed means individually administered standardized test spelling specific disorder arithmetic skills characterized specific impairment arithmetic skills solely explicable general retardation grossly inadequate schooling childs arithmetical performance significantly level expected basis age general intelligence school placement performance best assessed means individually administered standardized test arithmetic failure understand concepts underlying arithmetical operations lack understanding mathematical terms signs failure recognize numerical symbols difficulty understanding numbers relevant arithmetical manipulations difficulty properly aligning numbers understanding numbers relevant arithmeticinserting decimal pointssymbols calculations poor spatial organization arithmetical calculations inability learn multiplication tables satisfactorily mixed disorder scholastic skills characterized illdefinedinadequately conceptualised necessary residual category disorders arithmetical reading spelling skills significantly impaired disorder solely explicable terms general mental retardation inadequate schooling developmental disorders scholastic skills developmental expressive writing disorder developmental disorder scholastic skills unspecified disorders significant disability learning cannot solely accounted mental retardation visual acuity inadequate schooling includes knowledge acquisition disability nos ld nos learning disorder nos diagnostic statistical manual mental disorders 5th edition term used sld difficulties learning using academic skills indicated presence one following persisted least 6 months despite provision interventions target difficulties slowinaccurateeffortful reading difficulty understanding read difficulty spelling difficulty written expression difficulty mastering number sense number facts calculations difficulty math reasoning affected academic skills substantially quantifiably expected individuals chronological age least 15 standard deviation population mean age significant interference academic occupational performance activities daily living overserved ld confirmed means standardized achievement measures comprehensive clinical assessment learning difficulties start school years however may manifest till demands academics exceed individual capacities note diagnostic criteria met using history school reports psycho educational reports mention academic domains sub skills impairment impairment reading word reading accuracy reading rate accuracyfluency reading accuracy impairment written expression spelling accuracy grammar punctuation accuracy clarity organization written expression impairment mathematics number sense memorization arithmetic facts accurate fluent calculation accurate math reasoning specify current severity mild difficulties one two academic domains mild enough compensated functions well accommodationssupport service especially school years moderate marked difficulties one academic skills unlikely become proficient without intensive teaching school years accommodationssupportive services schoolhome complete activities accurately severe severe difficulties several academic skills unlikely become proficient without ongoing intensive teaching school years despite accommodationssupportive services schoolhome may complete activities accurately diagnostic statistical manual mental disorders 5th edition changes dsm 5 criteria learning disorderare overarching category follow spectral approach twin family studies revealed significant genetic environmental overlap amongst reading math written expression disorders hence lumping approach followed splitting approach reduces challenges associated defining subtype ld eg test scores differ across academic domainstests falling clinical threshold intelligence quotient iq achievement gap longer mentioned intellectual assessment required cases intellectual disability suspected focus early access intervention less assessment diagnosis psychoeducation parents consultation parents teachers required inclusion effect intervention symptom persistence yet another change practical challenges international classification diseases 11 potential changes icd 11 include change terminology developmental learning disorder includes impairment reading written expression mathematics impairment learning conceptually criterion continues follow discrepancy achievement according chronological age level intellectual functioning prevalence comorbidity per sahoo et al 2015 prevalence learning disorder ranges 2 105 prevalence learning disorders india 517 children6 male female ratio learning disorder 231 high comorbidity depicted table 2 impact presentation intervention disorder table 3table 2 comorbidity specific learning disordertable 3 comorbidity specific learning disorder impactassessment assessment children includes detailed clinical evaluation followed standard psychometric assessments childs cognitive abilities academic skills clinical evaluation children sld either brought parents selfreferred referral school children learning difficulties often labelled lazy stupid trouble makers comorbid behavioral symptoms often compared others perform well academics face punitive experiences home well school contexts clinical presentation quite variable children presenting primarily complaints poor academic performance whereas others present symptoms secondary poor academic performance may include school refusal oppositional behavior aggression poor motivation studies low selfesteem sadness mood crying spells changes sleep appetite excessive engagement extracurricular activities somatic complaints pain symptoms fatigue dissociative symptoms pseudo seizures dissociative sensory loss dissociative amnesia etc academic difficulties include writing slowly completing classwork homework poor handwriting omission long answer questions inability completewriting time spelling mistakes reading slowly reading word word replacing difficult words words similar pronunciation reading without punctuation mistakes arithmetic etc prior psychological testing psychiatrist obtain detailed history parents child followed examination child clinical evaluation structured include components listed table 4table 4 outline clinical evaluationpsychometric testing psychometric testing helps confirmation diagnosis planning intervention psychometric testing usually includes testing cognitive abilities testing academic abilities assessment childs level intelligence measuring iq done using standardized iq tests tests used include binetkamat test malins intelligence scale indian children misic wechslers intelligence scale children4th edition etc differing advantages refer table article intellectual disabilities misic provide performance iq verbal subscale iq fullscale iq children sld discrepancy verbal performance iqs performance iq usually higher another pattern named acidprofile described children may score low subtests arithmetic coding information digitspan wisc iv often reveals weaknesses verbal comprehension working memory processing speed14 assessment iq tests evaluate academic abilities need administered several tests depicted table 5 whichare useful evaluation academic abilities include nimhans index sld wide range achievement test test written language4 wechsler individual achievement test woodcockjohnson iiiiv tests achievements wjiii kaufman test educational achievement peabody individual achievement testrevised aston index batterytable 5 various tests achievementindian tests nimhans index sld commonly used battery indian context reliability validity tool established15 includes tests two levels level 57 years age group level ii 812 years tests tests level visuomotor skills copying three geometrical figures writing capital letters writing small letters writing alphabet preceding specified alphabet writing alphabet succeeding specified alphabet writing numbers serially writing numbers preceding specified number writing numbers succeeding specified number color cancellation test visual discrimination visual memory auditory discrimination auditory memory speechlanguage receptive expressive tests level ii number cancellation reading english passages spelling english words including schonells 15 words list reading comprehension english passages arithmetic subtest bender gestalt test visuospatial abilities definitions sld whether exclusionary inclusionary refer terms adequate intelligence appropriate instruction sociocultural factors difficult standardize pluralistic society india formulating indigenous assessment tools processing deficits intelligence testing proficiency reading writing mathematics several hundred languages spoken india gigantic task perhaps never able achieve complex issues compounded near total lack awareness teachers differences age school enrolment preliteracy quality teaching schools learning environment support home1617 iball test construction national brain research centre nbrc support department science technology government india available early 2019 multiple languages india curriculumbased assessments also used assess academic skills children tests name suggests based childs curriculum therefore wide comprehensive tests achievement grade level assessment device glad children learning problems schools developed national institute empowerment persons intellectual disability18 glad used age 6 years grades iv available english hindi includes mathematics another curriculum based test educational evaluation learning disability authored ms rukhshana sholapurwala19 diagnosis child ld one poorly academics impaired ability learning academic skills reading writing arithmetic spelling diagnose sld impairment intellectual disability subnormal intelligence neurological disorders visualhearing acuity problems inadequate schooling represent specific circumscribed type dysfunction cognitive processing contrast general learning difficulties cut across different domains academic nonacademic children specific learning difficulties possess average aboveaverage levels intelligence across many domains functioning specific deficits within narrow range academic skills words label considered children whose performance significantly expected usually 2 classes based general capacity learn thus concept unexpected academic difficulty central definition sld extent severity difficulties may vary child child fact children sld milder forms disability using rutters multiaxial diagnosis provide better understanding childs problems setting effective treatment plan example axis 1 attention deficit hyperactivity disorder axis 2 specific developmental disorder scholastic skills axis 3 average intellectual functioning axis 4 nil axis 5 punitive parenting differential diagnosis prior diagnosis sld evaluation rule following conditions primary causes poor academic performance borderline intelligence intellectual disability attention deficit hyperactivity disorder autism spectrum disorder school absenteeism due general medical conditions psychiatric disorders including mood disorders anxietydisorders psychosis discrepancy mother tongue medium schooling inadequate facilities schooling firstgeneration learners poor social support hearing impairment visual impairment neurological disorders example myopathy writers cramp early identification children atrisk important identify children atrisk sld national joint committee learning disabilities usa suggests risk indicators must checked screening evaluation table 6 lists risk indicators must included screening atrisk childrentable 6 risk indicators specific learning disorderthere screening tools available assist early identification one recent tools used india specific learning disabilityscreening questionnaire used school setting teachers20 recently dyslexia assessment languages india dali21 comprehensive screening assessment battery children risk dyslexia classes 15 developed dr nandini singh team nbrc support department science technology government india dali two screening tools junior screening tool classes 12 57 years middle screening tool classes 35 810 years addition 8 assessment batteries includes testing english mother tongue helps separating dyslexia language difficulties sample report figure 1 dali standardized validated across four languages hindi marathi kannada english across schools five centres 4840 children classes 15 work ongoing extend till grade x include mathematics number languages cover bengalee urdu tamilfigure 1 example report dalimanagement psychiatrist oftenthe primary contact person suspects assesses screens sld evaluates comorbidities treats psychiatrist also suggest simple handy remediation techniques outlined additionally ideal circumstances multidisciplinary team psychologist special educator occupational therapist language speech therapist pediatrician would useful holistic evaluation management disorders management implies helping core deficits disorder negative impact child family treating associated comorbidities overview management learning disorders discussed table 7table 7 overview managementmanagement core deficits disorder interventions classified accommodations facilitate student access educational material decreases burden stress child include larger size penpencils use grippers special papers provide tactile feedback use spell checkers audio books technological devices later may include voice recognition devices touchpad devices calculators individualizing assessments terms time length allowance breaks planned child may provided special services resource room mainstreamed modification task academic expectations child changed change delivery content instructional level subject matter tests implemented could include oral assignments writing short may focus either content spelling read aloud extra time learning lower level mathematics dropping language remedial education process help child acquire age appropriate skillsin foundation areas required forattaining knowledge pace potential interventions need systematic wellstructured multisensory include direct teaching learning time consolidation repeated revision factored attention variable child centric strategy taught learning content focus strengthening basics research hasshown effective intervention intensive 23 times week either individual level small group 12 using explicit systematic instruction phonological awareness decoding skills following improvement 50 children maintain gains 12 years intervention early 68 years usually fluency improves rather comprehension children improve continue show improvement next years changes brain occur remediation22 reflect plasticity brain depending type severity problem individual educational plan made child flowchart process individual educational plan shown figure 2figure 2 flowchart process individual educational planthe intervention planned determined agegrade child severity type deficits sand strengths usually 23 times week 34 years early years developing language skills basic skills reading writing mathematics area focus middle school besides basic skills children need learn concepts critical thinking problem solving secondary school accommodations modifications help child cope become prominent whilst educational interventions plan must also include components socio emotional development child choice techniques depends areas affected figure 3figure 3 flowchart interventions specific learning disordersspecific educational strategies reading problems decoding usually referred dyslexia phonological awareness needs increased ability understanding manipulate sound structure words emphasis paid phonemes smallest unit speech eg k kit b bat phonemic awareness includes ability hear manipulate individual phonemes phonemic awareness includes activities isolation training recognizing individual sounds wordstell first sound letter hat phoneme identity ability distinguish common sound differing words tell soundthat pod pan phonemic substitution replacing one phoneme another create new word catmat badbat oral segmenting able break word different sounds ban ban oral blending joining sounds form words besides phonemic awareness letter sound knowledge remediated phonics instruction works letter sound correspondence spelling patterns helps reading effective conjunction word recognition reading books repeated oral reading practice may help improving fluency reading comprehension skills linked larger language comprehension skills needs developed23 writing writing complex skill reading may cooccur reading disorder independently eye hand coordination ability segment phonemes essential24 basic motor functioning enhanced using hand exercises working clay beading finger tapping improve spelling phonics instruction teaching letter writing used following numbered arrow cues hiding letter visualizing writing letter utilizing numbered cues write letter finally checking letter compared sample master automaticity ability retrieve letters educational games activities useful target higher order skills writing essay involve planning organizing reviewing editing skills practice using concept maps different aids strategies employed writing clubs selfregulated strategy development shown useful25 mathematics number sense deficient children dyscalculia educational strategies include practicing number syntax linking numbers related digits eg 1234 one corresponds thousand two hundreds three tens 4 units repeated additions help internalizing number line drill practice also help remember number facts verbalization arithmetic concepts procedures operation helpful explicit instruction26 many remedial programs developed usually work children reading writing difficulties sonday system children mathematic difficulties number race graphogame27 special areas children poor language skills many children first generation learners poor exposure english language would added difficulties aspects academic achievement children often overidentified suffering slds sometimes may occur however children besides specific intervention english enrichment program would useful use technology assistive devices help children overcome obstacles save time technological tools vary voice recognition programs users dictate ideas watch appear computer screens recording devices word processors concept mapping tools smart pens educational apps issoftware specially designed children sldgrahphogame use universal design allows easy access children sld whilst child severe difficulties may use computer write would helpful encourage child try write brain activity better similarly learning basic concepts maths useful daily life choice curriculum india various boards running different curriculum state boards indian councilof secondary education central board secondary education national open school international ones international baccalaureate boards varying educational standards teaching learning methods choice subjects help children disability based factors parents teachers may consider shifting curriculum first generation learners low socioeconomic status may add disorder especially child educated mother tongue sld shown similar universal neuropsychological features across alphabetic english hindi logographic chinese orthographies depending regularity language difficulty would vary hindi consistent english alphabets sound match consistently hindi english however changing medium instruction attempted early years academic provisions given children ith learning disorder described table 86table 8 various provisions specific learning disorder example maharashtramitigating impact specific learning disorder psychoeducation family explaining disorder child would necessary family counselling may also required combat negative attitudes behavior28 low selfesteemwhich common finding require specific intervention29 protective factors foster resilience useful include selfadvocacy tools identifying strengths improving social connections10 managing comorbidity comorbidity rule rather exception may presenting illness attention deficit hyperactivity disorder adhdautism spectrum disorder may consequence depression may blended disorder anxiety behavioral symptoms however research treating comorbidities limited studies use exclusion criteria adhd frequently occurring disorder requires treatment even assessing interferes results treatment disorders required simultaneously though may lead additive effect pharmacotherapy adhd varying effect reading disability10 cognitive behavior therapy mindfulness meditation shown improve emotional health latter also improving attention10 anxiety depression disruptivebehaviordisorder impulsivebehavior autism conductdisorders sld also require appropriate intervention flowchart overview assessment management shown figure 4figure 4 flowchart overall process assessment managementprevention prediction cognitive skills predict literacy letter sound knowledge phoneme awareness whilst group may differentiating factors translating individual level predict easy30 welltrained teacher would able identify children struggling could supported checklists usa response intervention used prevention treatment detection model depicted figure 5 would start treatment identification failure sets could encouraged schools may integrate help sarva shiksha abhiyan early intervention risk children dyslexia could phonological skill trainingfigure 5 response intervention modelbesides phonological processes communication impairment deficits naming speed measured ran predictive future sld language impairments risk reading comprehension difficulties future poor readers often come large families poor reading skills parents better outcomes decoding seen parents teach print concepts comprehension parents share reading offspring intervention half three quarters children improve early intervention also prevents complication developing poor reading fluency comprehension22 law specific learning disorder sld one bench mark disabilities encompassed rights persons disability act 2016 ensures following31 government local authorities required ensure children benchmark disabilities access free education appropriate environment till 18 years age sld difficult quantify disability government institutions higher education higher education institutions receiving aid government shall reserve 5 seats persons benchmark disabilities includes specific ld upper ag