Learning disorders

LEARNING DISORDERS

1. Learning disorders Dr Parag Moon Senior resident, Dept. of Neurology, GMC, Kota.

2. Definition A disorder in one or more of basic psychological processes involved in understanding or in using language, spoken or written, that may manifest itself in imperfect ability to listen, think, speak, read, write, spell, or to do mathematical calculations, including conditions such as perceptual disabilities, brain injury, minimal brain dysfunction, dyslexia, and developmental aphasia. [Individuals with disability education act IDEA 2004]

3. Learning Disability Disorders not included - learning problems that are primarily result Visual , hearing, or motor disabilities Mental retardation Emotional disturbance Environmental , cultural, or economic disadvantage.

4. Learning Disabilities Characterized by academic underachievement in reading, written expression, or mathematics in comparison with overall intellectual ability of child. Children with learning disorders often find it difficult to keep up with their peers in certain academic subjects, whereas they excel in others.

5. Significant difference between student’s scores on test of general intelligence (e.g. IQ test such as WISC-IV) and scores obtained on achievement test (e.g. Woodcock Johnson Achievement Test). If score on IQ test at least two standard deviations (30 points) higher than his or her scores on achievement-learning disability.

6. Heredity - tends to run in families Illness or injury during pregnancy and delivery- use of drugs, alcohol during pregnancy, RH incompatibility, premature or prolonged labor or lack of oxygen or low weight at birth. Incidents after birth. Head injuries, nutritional deprivation, poisonous substances, (e.g., lead), and child abuse can contribute. Causes

7. 5% of children suffer from some form of learning disability. Dyslexia most common-80-85%. Twice as common in males as in females 25% of Learning disabilities have associated Attention Deficit/Hyperactive Disorder-ADHD 35% of children with learning disabilities drop out of high school. Epidemiology

8. Types of learning disorders Dyslexia A language and reading disability Dyscalculia Problems with arithmetic and math concepts Dysgraphia A writing disorder resulting in illegibility Dyspraxia (Sensory Integration Disorder) Problems with motor coordination Central Auditory Processing Disorder Difficulty processing and remembering language-related tasks Non-Verbal Learning Disorders Trouble with nonverbal cues, e.g., body language; poor coordination, clumsy Visual Perceptual/Visual Motor Deficit Reverses letters; cannot copy accurately; Language Disorders (Aphasia/Dysphasia) Trouble understanding spoken language; poor reading comprehension

9. Reading achievement below expected level for child's age, education, & intelligence, with impairment interfering significantly with academic success or daily activities involving reading Developmental alexia-developmental deficit in recognition of printed symbols Dyslexia replaced by broader term learning disorder Reading disorders

10. Described as neurobiological disorder with a genetic origin. Deficit in phonological processing skills. Asymmetry of left planum temporale Lesion in splenium of corpus callosum Altered left temporal blood flow Visual magnocellular system (which normally contains large cells) containing more disorganized and smaller cell bodies than expected. Genetic - 35 to 40% of first-degree relatives of reading disorder have some reading disability Etiology

11. Typical vs. Atypical Migration

12. Blood Flow Abnormalities

13. Usually identified by 7 years (second grade) Characterized by omissions, additions and distortions of words. Have difficulty in distinguishing between printed letter characters and sizes, especially those that differ only in spatial orientation and length of line. Child's reading speed is slow, often with minimal comprehension. May start a word either in middle or at end of printed or written sentence Have age appropriate ability to copy from written or printed text, but nearly all spell poorly. Clinical features

14. Problems pronouncing multisyllabic words ( e.g.“aminals ” for“animals ” and “ sblanation ” for “explanation”). Many false starts, hesitations, and nonspecific terms Dislike and avoid reading and writing.

15. Reading achievement, as measured by individually administered standardized tests of reading accuracy or comprehension, is substantially below that expected given person's chronological age, measured intelligence, and age-appropriate education. Disturbance in Criterion A significantly interferes with academic achievement or activities of daily living that require reading skills. If sensory deficit is present, reading difficulties are in excess of those usually associated with it. DSM-IV Diagnostic Criteria for Reading Disorder

16. Either of following must be present: Score on reading accuracy and/or comprehension at least 2 standard errors of prediction below level expected on basis of child's chronological age and general intelligence, with both reading skills and IQ assessed on individually administered test standardized for child's culture and educational system. History of serious reading difficulties, or test scores that met Criterion A(1) at earlier age, plus score on spelling test that at least 2 standard errors of prediction below level expected on basis of child's chronological age and IQ. Disturbance described in Criterion A significantly interferes with academic achievement or with activities of daily living that require reading skills. ICD-10 Diagnostic Criteria for Specific reading disorder

17. Disorder is not direct result of defect in visual or hearing acuity, or of neurological disorder. School experiences within average expectable range (i.e., there have been no extreme inadequacies in educational experiences). Exclusion clause : IQ is below 70 on individually administered standardized test. ICD-10 Diagnostic Criteria for Specific reading disorder

18. Special individual educational programmes Teaching child to make accurate associations between letters and sounds. After individual letter-sound have been mastered, remediation can target larger components of reading such as syllables and words. Positive coping strategies include small, structured reading groups that offer individual attention and make it easier for child to ask for help. Treatment

19. Orton Gillingham, Direct Instructional System for Teaching and Remediation (DISTAR), Merill program, Science Research Associates, Inc. (SRA) Basic Reading Program , Introducing whole words first and then teach children how to break them down and recognize sounds of syllables and individual letters in word. Teaches to recognize whole words through use of visual aids and bypasses sounding-out process. Parent counselling Treatment of coexisting emotional and behavioral problems

20. Dyscalculia, congenital arithmetic disorder, acalculia , and developmental arithmetic disorder Have difficulty learning and remembering numerals, cannot remember basic facts about numbers, are slow and inaccurate in computation. Poor achievement in four groups of skills: Linguistic skills (those related to understanding mathematical terms and converting written problems into mathematical symbols) Perceptual skills (ability to recognize and understand symbols and order clusters of numbers) Mathematical skills (basic addition, subtraction, multiplication, division, and following sequencing of basic operations) Attentional skills (copying figures correctly and observing operational symbols correctly). Mathematics disorder

21. Affect 1 percent of school-age children More common in females Comorbid with reading disorder and disorder of written expression. Early theory-neurological deficit in right cerebral hemisphere Currently, cause is thought multifactorial -maturational, cognitive, emotional, educational, and socioeconomic factors

22. Detected during 2 nd and 3 rd grades Difficulty in learning number names, remembering signs for addition and subtraction, learning multiplication tables, translating word problems into computations, doing calculations at expected pace. Has significant problems with concepts, such as counting and adding even one-digit numbers, compared with classmates of same age. Clinical features

23. Classified mathematics disorder following: Difficulty learning to count meaningfully; Difficulty mastering cardinal and ordinal systems; Difficulty performing arithmetic operations Difficulty envisioning clusters of objects as groups.

24. Mathematical ability, as measured by individually administered standardized tests, is substantially below that expected given person's chronological age, measured intelligence, and age-appropriate education. Disturbance in Criterion A significantly interferes with academic achievement or activities of daily living that require mathematical ability. If a sensory deficit is present, difficulties in mathematical ability are in excess of those usually associated with it. DSM-IV Diagnostic Criteria for Mathematics Disorder

25. Score on standardized arithmetic test at least 2 standard errors of prediction below level expected on basis of child's chronological age and general intelligence. Scores on reading accuracy and comprehension and on spelling within normal range (±2 standard deviations from mean). No history of significant reading or spelling difficulties. School experience within average expectable range (i.e. no extreme inadequacies in educational experiences). ICD 10 diagnostic criteria for Specific disorder of arithmetical skills

26. Arithmetical difficulties present from early stages of learning arithmetic. Disturbance described in Criterion A significantly interferes with academic achievement or with activities of daily living that require arithmetical skills. Exclusion clause : IQ is below 70 on individually administered standardized test. ICD 10 diagnostic criteria for Specific disorder of arithmetical skills

27. Most effective treatments for mathematics disorder combine teaching mathematics concepts with continuous practice in solving math problems. Flash cards, workbooks, and computer games Project MATH, a multimedia self-instructional or group instructional in-service training program. Development of positive problem-solving skills in social arena as well as in mathematics. Treatment

28. Dysgraphia , spelling disorder, spelling dyslexia Characterized by writing skills that are significantly below expected level for child's age and intellectual capacity. Components of writing disorder include poor spelling, errors in grammar and punctuation, and poor handwriting. Spelling errors-most common difficulties which are most often phonetic errors Eg - fone for phone, or beleeve for believe. Disorder may result from combined effects of one or more of following: expressive language disorder, mixed receptive-expressive language disorder and reading disorder. Disorder of Written Expression

29. Poor performance on composing written text, including handwriting and impaired ability to spell and to place words sequentially in coherent sentences In addition to spelling mistakes, he may have serious grammatical mistakes, such as using incorrect tenses, forgetting words in sentences, and placing words wrong order. Punctuation may be incorrect with poor ability to remember which words begin with capital letters Clinical features

30. Letters are not legible, inverted letters, and mixtures of capital and lowercase letters in given word. Poor organization of written stories, which lack critical elements such as “where,” “when,” and “who” or clear expression of plot. Clinical features

31. Writing skills, as measured by individually administered standardized tests (or functional assessments of writing skills), are substantially below those expected given person's chronological age, measured intelligence, and age-appropriate education. Disturbance in Criterion A significantly interferes with academic achievement or activities of daily living that require composition of written texts (e.g., writing grammatically correct sentences and organized paragraphs). If a sensory deficit is present, difficulties in writing skills are in excess of those usually associated with it. DSM-IV Diagnostic Criteria for Disorder of Written Expression

32. Score on standardized spelling test at least 2 standard errors of prediction below level expected on basis of child's chronological age and general intelligence. Scores on reading accuracy and comprehension and on arithmetic are within normal range (±2 standard deviations from mean). No history of significant reading difficulties. School experience within average expectable range (i.e., there have been no extreme inadequacies in educational experiences). ICD 10 diagnostic criteria for Specific spelling disorder

33. Spelling difficulties present from early stages of learning to spell. Disturbance described in Criterion A significantly interferes with academic achievement or with activities of daily living that require spelling skills. Exclusion clause: IQ is below 70 on individually administered standardized test. ICD 10 diagnostic criteria for Specific spelling disorder

34. Direct practice in spelling and sentence writing as well as review of grammatical rules. Intensive and continuous administration of individually tailored, one on- one expressive and creative writing therapy appears to effect favorable outcome. Associated secondary emotional and behavioral problems-given prompt attention, with appropriate psychiatric treatment and parental counseling . Treatment

35. Disorders in learning that do not meet criteria for any specific learning disorder. Might include problems in all three areas (reading, mathematics, written expression) That together significantly interfere with academic achievement On performance tests measuring each individual skill is not substantially below that expected given person's chronological age, measured intelligence, and age-appropriate education. Learning Disorder Not Otherwise Specified

36. Mixed disorder of scholastic skills Ill-defined, inadequately conceptualized (but necessary) residual category of disorders Both arithmetical and reading or spelling skills are significantly impaired, But disorder not solely explicable in terms of general mental retardation or inadequate schooling. Used for disorders meeting criteria for specific disorder of arithmetical skills and either specific reading disorder or specific spelling disorder.

37. Tests of Intelligence Wechsler Scales (most common): Wechsler Preschool & Primary Scale of Intelligence WPPSI-III (2.6 – 7.3 yrs) Wechsler Intelligence Scale for Children WISC-IV (6.0 – 16.11 yrs) Wechsler Adult Intelligence Scale WAIS-III (16 – 89 yrs) Other commonly used scales: Stanford-Binet Intelligence Scale Kaufman Assessment Battery for Children Woodcock-Johnson Tests of Cognitive Ability, etc.

38. WISC-IV Verbal Comprehension Index Similarities, vocabulary, comprehension, information, word reasoning Perceptual Reasoning Index Block design, picture concepts, matrix reasoning, picture completion Working Memory Index Digit span, letter-number sequencing, arithmetic Processing Speed Index Coding, symbol search, cancellation

39. Achievement Tests Group Administered Tests Stanford Achievement Tests (Stanford 9) California Achievement Tests (CAT) IOWA Tests of Basic Skills, etc. Individually Administered Tests Wide Range Achievement Tests 3 (WRAT 3) Wechsler Individual Achievement Tests (WIAT) Woodcock-Johnson Psychoeducational Battery, rev (WJ-R), etc.

40. Celebrities with dyslexia Tom Cruise Walt Disney Henry “The Fonz ” Winkler Magic Johnson

41. Kaplan & Sadock's Comprehensive Textbook of Psychiatry. 10th ed. Vol. 2. Lyon G. Learning disability; Spring 1996 Vol 6 no1:54-76 Cragg L, Nation K. Exploring written narrative in children with poor reading comprehension. Educational Psychology. 2006;26:55–72 . References