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Learning

1. LEARNING DISORDERS DEPARTMENT OF PAEDIATRICS, JNIMS Department of Pediatrics, JNIMS 1

2. SPECIFIC LEARNING DISORDERS Specific learning disorders (SLDs) are neurodevelopmental conditions typically seen in school-going children Characterized by impairment in at least one of three major areas: Reading ( Dyslexia ) Written expression ( Dysgraphia ) Math ( Dyscalculia ) Occur in 1.6-15 % of Indian children With profound academic and psychosocial consequences Department of Pediatrics, JNIMS 2

3. Department of Pediatrics, JNIMS 3 DYSLEXIA

4. DYSLEXIA Federal/Legal Definition: “Unexpected difficulty in reading for an individual who has the intelligence to be a much better reader, most commonly caused by a difficulty in the phonological processing which affects the ability of an individual to speak, read and spell.” In typical readers, development of reading and intelligence quotient (IQ) are dynamically linked over time In dyslexic readers, developmental uncoupling occurs between reading and IQ over time Which means reading achievement is significantly below expectations for the individual’s IQ Department of Pediatrics, JNIMS 4

5. Department of Pediatrics, JNIMS 5 Developmental uncoupling of reading and IQ over time in Dyslexia Sally ES, Bennett AS. Nelson’s Textbook of Pediatrics 21 st ed. Philadelphia: Elsevier; c2019. Chapter 50, Dyslexia ; p.1620-1630

6. Department of Pediatrics, JNIMS 6 Achievement gap between typical and dyslexic readers is evident as early as 1 st grade and persists through adolescence Sally ES, Bennett AS. Nelson’s Textbook of Pediatrics 21 st ed. Philadelphia: Elsevier; c2019. Chapter 50, Dyslexia ; p.1620-1630

7. EPIDEMIOLOGY Dyslexia is the most common specific learning disability Accounting for 80% of all children identified to have SLDs It is also the most common neurobehavioral disorder With prevalence of around 17.5-21% Occurs equally in males and females Department of Pediatrics, JNIMS 7

8. ETIOLOGY Dyslexia is familial disorder 50% rule: For a person with dyslexia, 50% chance that one of his/her parents has dyslexia 50% chance that his/her siblings have dyslexia 50% chance that his/her offsprings have dyslexia Genome-wide association studies (GWAS) have demonstrated that a large number of genes are involved, with each contributing a small amount towards the expression of dyslexia Department of Pediatrics, JNIMS 8

9. PATHOGENESIS Dyslexia reflects deficits specifically within the Phonologic Component of the language system engaged in processing the sounds of speech Individuals with dyslexia have difficulty developing an awareness that spoken words can be segmented into smaller elemental units of sounds ( phonemes ) Disruption of attention mechanisms may also play an important role Functional brain imaging demonstrates inefficient functioning of left hemisphere posterior reading systems of the brain A pattern referred to as the neural signature of dyslexia Department of Pediatrics, JNIMS 9

10. Department of Pediatrics, JNIMS 10 Inefficient functioning of left posterior reading systems of the brain, involved in word analysis and word formation The Neural Signature for Dyslexia: Sally ES, Bennett AS. Nelson’s Textbook of Pediatrics 21 st ed. Philadelphia: Elsevier; c2019. Chapter 50, Dyslexia ; p.1620-1630

11. CLINICAL MANIFESTATIONS Dyslexia manifests as problems in both spoken and written language Spoken language difficulties manifest as slow, labored and effortful approach to reading with: Mispronunciations Lack of fluency with many pauses Need for time to summon an oral response Repeated attempts to vocalize words These reflect sound-based difficulties , not knowledge-based difficulties Department of Pediatrics, JNIMS 11

12. CO-MORBID CONDITIONS Co-morbidities known to be associated with dyslexia are – Attention-deficit/hyperactivity disorder (ADHD) Anxiety Depression Autism spectrum disorder (ASD) Developmental co-ordination disorder Department of Pediatrics, JNIMS 12

13. DIAGNOSIS Dyslexia is a clinical diagnosis Detailed history, clinical evaluation and neuropsychological assessment (tests of language, phonology, reading, fluency, spelling and intellectual ability) Dyslexia is distinguished from others disorders that prominently feature reading difficulties by the unique, circumscribed nature of the phonologic deficit which does not intrude into other linguistic or cognitive domains No role for genetic studies, neuroimaging in the diagnosis of dyslexia Department of Pediatrics, JNIMS 13

14. 1. DETAILED HISTORY Nature of learning difficulties in detail Chronology and progression of difficulties Academic performance and examination of reports from school (notebooks, report cards, assignments) Child’s strengths and interests Birth history Developmental history Behavioral history Any other chronic diseases Department of Pediatrics, JNIMS 14

15. 2. CLINICAL EVALUATION Anthropometry Head-to-toe examination for any dysmorphic features Neurocutaneous markers Neurodevelopmental assessment Learning screening Hearing assessment Vision assessment Department of Pediatrics, JNIMS 15

16. 3. NEUROPSYCHOLOGICAL ASSESSMENT Evaluation of cognitive level and academic abilities using standardized psychometric tests: WISC V: Wechsler Intelligence Scale for Children V CTOPP-2: Comprehensive Test of Phonological Processing-2 WIAT-III: Wechsler Individual Achievement Test – 3 rd edition TOWRE: Test Of Word Reading Efficiency Nelson-Denny Reading Test: Timed-reading tests Multidisciplinary assessments by occupational therapist Department of Pediatrics, JNIMS 16

17. Department of Pediatrics, JNIMS 17 Developmental uncoupling of reading and IQ over time in Dyslexia Sally ES, Bennett AS. Nelson’s Textbook of Pediatrics 21 st ed. Philadelphia: Elsevier; c2019. Chapter 50, Dyslexia ; p.1620-1630

18. MANAGEMENT Management of dyslexia demands a life-span perspective Early in life, the focus is on remediation of reading difficulties: Effective intervention programs provide systematic instruction in 5 key areas: phonemic awareness, phonics, fluency, vocabulary and comprehension strategies Later-on in life, the focus is on provision of accommodations: Extra time for reading and writing assignments as well as examinations Teaching the students to listen to texts instead (Text-to-speech programs) Department of Pediatrics, JNIMS 18

19. SUPPORTIVE CARE Encourage parents to – Foster the child’s strengths Understand the challenges from the perspective of neurologic functioning Support the child’s learning needs Promote self-care and self-esteem Department of Pediatrics, JNIMS 19

20. PROGNOSIS Dyslexia is a permanent diagnosis with familial predisposition IQ/DQ is usually normal With time, reading accuracy improves but fluency of speech remains poor There will be great difficulty in learning of a second language Parents should be informed that with proper support, dyslexic children can succeed in a range of future occupations Department of Pediatrics, JNIMS 20

21. REFERENCES Sally ES, Bennett AS. Nelson’s Textbook of Pediatrics 21 st ed. Philadelphia: Elsevier; c2019. Chapter 50, Dyslexia ; p.1620-1630. Kenneth LG. Nelson’s Textbook of Pediatrics 21 st ed. Philadelphia: Elsevier; c2019. Chapter 51, Math and Writing Disabilities ; p.1631-1650. Nandita DS, Somasundaram A, Swati V. Indian Academy of Pediatrics (IAP) Standard Treatment Guidelines 2022. Chapter 81, Specific Learning Disorders; p1-8. Department of Pediatrics, JNIMS 21

22. Department of Pediatrics, JNIMS 22 THANK YOU