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specific learning disorder

1. SPECIFIC LEARNING DISORDER Dr. Devashish Palkar Dr. Dimple Dadarwala

2. Introduction History DSM & ICD Epidemiology Specific learning disorder with impairment in reading Specific learning disorder with impairment in mathematics Specific learning disorder with impairment in written expression Comorbidities Complications Conclusion

3. Introduction Specific learning disorder in youth is a neurodevelopmental disorder produced by the interactions of genetic and environmental factors that inf luence the brain's ability to perceive or process verbal and nonverbal information efficiently.

4. Definition A disorder in one or more of the basic psychological processes involved in understanding or in using language, spoken or written, which may manifest itself in an imperfect ability to listen, think, speak, read, write, spell, or do mathematical calculations.

5. The 1977 federal definition of LD included three major components: severe discrepancy between achievement and intellectual ability, Heterogeneity - manifest in various academic domains (e.g., speaking, listening, basic reading, reading comprehension, math calculation, written expression); and Exclusion - SLD is not identified when the primary cause is mental retardation, emotional disturbance, sensory disorder, social, or economic disadvantage.

6. H ISTO R Y 1877 Rudolph Berlin coined the term dyslexia 1896, British physician W. Pringle Morgan - first to describe reading difficulty in a 14- year-old boy. In the 1920s, the neurologist Samuel Orton - a neurological basis for the disorder, that delayed development of specialization of the left hemisphere for language was potentially causal. The term “Learning Disability” was given by Samuel Kirk , 1962 Gerstmann described Gerstmann syndrome in 1960s 1970s - pinpointed the cause as deficits in phonological processing.

7. T E R MS Phoneme : Smallest sound units in a word that distinguishes one word from another (e.g., the word “peach” has three phonemes: /p/ /ea/ /ch/; the phoneme /p/ distinguishes the word “peach” from “teach”). Phonemic awareness : awareness that there are discrete speech sounds (phonemes) in speech. Phonological awareness : awareness that spoken language comprises discrete units – words, syllables and phonemes. Phonological coding : Translating the letters of a written word into speech patterns to identify the word and gain access to its meaning. • Orthography : The representation of the sounds of a language by written or printed symbols.(EG. Incredible - / ɪ n ˈ kr ɛ d ɪ b( ə )l/ )

8. DSM DSM-5 combines the DSM-IV diagnoses of reading disorder, mathematics disorder, and disorder of written expression and learning disorder NOS into a single diagnosis : Specific learning disorder. Learning deficits in reading, written expression, and mathematics in the DSM-5 are designated using specifiers.

9. ICD 10 F81 Specific developmental disorders of scholastic skills  F81.0 Specific reading disorder  F81.1 Specific spelling disorder  F81.2 Specific disorder of arithmetical skills  F81.3 Mixed disorder of scholastic skills  F81.8 Other developmental disorders of scholastic skills  F81.9 Developmental disorder of scholastic skills, unspecified

10. ICD 11 6A03 Developmental learning disorder  6A03.0 Developmental learning disorder with impairment in reading  6A03.1 Developmental learning disorder with impairment in written expression  6A03.2 Developmental learning disorder with impairment in mathematics  6 A 03 . 3 D e v e l o p m e n t a l l e a r n i n g d i so r d e r w i t h o t h e r s p e c i fi e d i m p a i r m e n t of learning  6A03.Z Developmental learning disorder, unspecified

11. DSM-5 DIAGNOSTIC CRITERIA FOR SPECIFIC LEARNING DISORDER A. Presence of at least one of the following for 6 months, despite interventions: Inaccurate or slow and effortful word reading (e.g., reads single words aloud incorrectly or slowly and hesitantly, frequently guesses words, has difficulty sounding out words). Difficulty understanding the meaning (e.g., may read text accurately but not understand the sequence, or deeper meanings of what is read). Difficulties with spelling (e.g., may add, omit, or substitute vowels or consonants). Difficulties with written expression (e.g., makes multiple grammatical or punctuation errors; poor paragraph organization; written expression of ideas lacks clarity). 5. Difficulties mastering number sense or calculation (e.g., counts on fingers to add single-digit numbers; gets lost in the midst of arithmetic computation and may switch procedures). 6. Difficulties with mathematical reasoning (e.g., difficulty applying mathematical concepts, facts to solve quantitative problems).

12. B. The affected academic skills are below those expected for the individual's chronological age, and cause significant interference with functioning. C. The learning difficulties begin during school-age years but may not become fully manifest until the demands exceed the individual's limited capacities (e.g., as in timed tests, reading or writing lengthy complex reports for a tight deadline, excessively heavy academic loads). D. The learning difficulties are not better accounted for by intellectual disabilities, u n c o r r e c t e d v i s ua l o r a u d i t o r y ac u i t y , o t h e r m e n t a l o r n e u r o l o g i c al d is o r d e r s , psychosocial adversity or inadequate educational instruction.

13. Specify if: 31 5.00 (F81 .0) With impairment in reading: 31 5.2 (F81 .81) With impairment in written expression: 31 5.1 (F81 .2) With impairment in mathematics: Specify current severity: Mild Moderate Severe

14. EPIDEMIOLOGY SLD of all types affects approximately 10 % of youth. SLD occurs two to three times more often in males than in females. Reading and written expression disorder are more common in boys and mathematics disorder is more in girls. At least 75 % of all individuals identified as having SLD have reading disorder The prevalence of a disorder of written expression and mathematics disorder is about 6 percent of school-aged children There is an increased risk of 4 to 8 times in first-degree relatives for reading deficits, and about 5 to 10 times for mathematics deficits.

15. SPECIFIC LEARNING DISORDER WITH IMPAIRMENT IN READING

16. Multiple skills are involved in reading. These include the awareness that spoken language can be segmented into smaller units (words, syllables, phonemes) mapped onto written visual symbols; the ability to identify letters and words rapidly (orthographic awareness); and the ability to extract meaning from this written language.

17. Definition Lyon and co-workers in 2003 specified the following: Dyslexia is a SLD that is neurobiological in origin. It is characterized by difficulties with inaccurate word recognition and poor spelling and decoding abilities . These difficulties typically result from a deficit in the phonological component of language. “dyslexia” - Greek origin, with a meaning “impaired” “word.”

18. Etiology Neurological Factors Genetic Factors Cognitive Factors     Phonological Theory Rapid Auditory Processing Theory Cerebellar Theory Visual/Magnocellular Theory

19. Neurological Factors fMRI - show a distinct brain activation profile during reading. Basic word reading activates three systems in the left side of the brain : (2) a left parietotemporal system - analyzing the written word (1) an anterior system in the left inferior frontal region - phoneme production (vocalizing words silently or out loud); • (3) a left occipitotemporal system - automatic word recognition In contrast, in RD demonstrate underactivation in both posterior systems (left temporoparietal, left occipitotemporal) and increased activation in the left inferior frontal gyrus, right temporal and tempoparietal regions. So they rely more heavily on right-sided posterior brain systems to read via memorization rather than by sound–symbol linkages and so continue to struggle to read unfamiliar words.

20. I m aging MRI studies - planum temporale in the left brain shows less asymetry than the right brain. PET studies - left temporal blood flow patterns during language tasks differ between children with and without SLD. Cell analysis studies - the visual magnocellular system (which normally contains large cells) contains more disorganized and smaller cell bodies than expected.

21. Genetic Factors RD is highly familial and heritable. • Upto 50 % of children of parents with RD and 50 % of siblings of a child with RD may have the disorder. Twin studies - high concordance rates for RD. Genetic factors account for 69 to 87 % and 13 to 30 % is due to environmental factors. M o le c ula r g e n e tic s t u d i e s o f R D h a v e r e po r t e d s e v e r al s us c e p tibi lit y lo c i o n chromosomes 1p, 2p, 3p, 6p, 11p, 15q, 18p, and Xq27.3. C h r o m o s o m e 1 p – c o mm on s usc e p tibi lit y lo c u s fo r b o t h r e adi n g d i s o r d e r a n d inattention dimension of ADHD

22. Cognitive Factors D iv e r s e h y p o t h e s e s e x i s t f o r t h e und e r l y in g c o g ni t iv e d e f i c it s i n R D , including     Phonological Theory Rapid Auditory Processing Theory Cerebellar Theory Visual/Magnocellular Theory

23. 1. Phonological Theory Most widely accepted. According to this model, the core difficulty in RD is a specific deficit in the representation, storage, or retrieval of speech sounds . At the neurological level, there is a dysfunction of lefthemisphere perisylvian brain areas that support phonological representation. Double-deficit hypothesis - phonological and naming-speed deficits Naming-speed deficits - slow rate in the recognition and retrieval of the names of symbol. Eg: naming colors, letter or objects. Double deficit leads to a more profound form of RD T r i p l e - d e fi c i t mo d e l - T h e a d d i t i o n o f a n o r t h o g r a p h i c d e f i ci t t o t h e do u b l e - d e f i ci t m o d e l . Individuals with orthographic deficits have difficulty in recalling written words.

24. 2. Rapid Auditory Processing Theory Auditory deficit in the perception of short or rapidly varying sounds . Studies demonstrated that individuals with RD perform poorly on auditory tasks (e.g., frequency discrimination) and exhibit abnormal neurophysiological responses to various auditory stimuli. More recently, perceptual deficits in the processing of acoustic structure at the level of the syllable - rhythm detection is included. This involves detection of modulation of the speech waveform.

25. 3. Cerebellar Theory The cerebellum plays a role in motor control and so in speech articulation deficient phonological representations. Critical role in specific timing required for some aspects of speech perception (e.G., Distinguishing “rapid” and “rabid”). Plays a role in the automatization of activities, such as typing and reading. A weak capacity to automatize would impair learning and fluency. Brain imaging studies have revealed anatomical, metabolic, and activation differences in the cerebellum of individuals with RD.

26. 4. Visual/Magnocellular Theory most ubiquitous and influential theories of dyslexia emphasizes a visual contribution to reading problems Proposed visual problems include unstable binocular fixations, poor visual tracking, abnormalities in perception of visual motion and poor contrast sensitivity. mechanism - disruption of the magnocellular pathway deficits anywhere along the magnocellular pathway can affect the spatiotemporal gating functions that are essential for reading a text by spotlighting the individual letters of a text in a sequential fashion.

27. Signs of Reading Disorder Kindergarten  Lack of interest in playing games with language sounds (e.g., repetition, rhyming)  Trouble learning nursery rhymes  Failure to recognize letters in their own name  Trouble remembering names of letters, numbers, or days of the week  Unable to recognize phonemes (e.g., does not know which of the set of words “dog,” “man,” “car” starts with same sound as “cat”) Primary Grades (Grades 1–3)  Receives reports of “not doing well in school”  Unable to read one-syllable words, such as “mat” or “top”  problems in connecting sounds and letters (e.g., “big” for “got”)  Difficulty in sequencing numbers and letters

28. Middle Grades (Grades 4–6)  Mispronounces or skips parts of long words (e.g., says “conible” for “convertible” and “aminal” for “animal”)  Confuses words that sound alike (e.g., “tornado” for “volcano”)  Trouble remembering dates, names, telephone numbers  Gets the first part of word correct, then guesses wildly (e.g., reads “clover” as “clock”)  Poor comprehension  Trouble completing homework or tests on time  Terrible spelling  Fear of (refuses) to read aloud, avoids reading High School, College, Work  Slow, effortful reading of single words and connected text  Trouble pronouncing multisyllable words  Frequent need to reread material to understand  Avoids activities that demand reading (reading for pleasure, reading instructions)

29. Assessment Psychoeducational testing, is critical in determining these deficits. The reading subtests useful are Woodcock-Johnson Psycho-Educational Battery- Revised, and The Peabody Individual Achievement Test-Revised Test of Word Reading Efficiency (TOWRE);

30. NIMHANS INDEX FOR SLD  LEVEL -1 YOUNGER STUDENTS (5-7 YEARS)  Level II OLDER STUDENTS (8 to 12 years)

31. ATTENTION Simple Colour Cancellation test. Double Colour Cancellation test. 2. VISUAL DISCRIMINATION 3. VISUAL MEMORY

32. 4. AUDITORY DISCRIMINATION AUDITORY MEMORY SPEECH AND LANGUAGE Verbal language expression 7. VISUAL-MOTOR SKILLS

33. 8. WRITING SKILLS Capital letters Small letters Write the letter that comes before and after NUMBERS Write the numbers up to 20 Write the number that comes before and after

34. Level II OLDER STUDENTS (8 to 12 years) ATTENTION Number cancellation LANGUAGE Reading of english passages Comprehension Spelling test (schonell's list) Copying of english passages ARITHMETIC SUBTEST BENDER GESTAULT TEST

35. Course and Prognosis RD is persistent and does not remit with age or time in the absence of effective intervention. Many eventually learn to read, at basic level, using various compensatory strategies, but they rarely read for pleasure. Problems in persist into adulthood, at which time the main problem is in terms of speed rather than accuracy of decoding single words. • Young adults rely more on memory-based rather than analytic strategies to assist in word identification.

36. Treatment psychological Typically carried out in education settings or specialized psychology clinics T h e ps y c hiatr is t ’ s p r i m a r y r o l e i s t o i n s ti g a t i n g p ha r m a c o lo g i c al o r treatment for coexisting mental health problems R e m e diatio n - fo c u s on dir e c t ins t r u c ti o n t ha t l e a d s a c hil d ' s atte nti o n t o t h e connections between speech sounds and spelling. After individual letter- sound associations have been mastered, larger components of reading such as syllables and words are targeted. Positive coping strategies include small, structured reading groups that offer individual attention and make it easier for a child to ask for help.

37. Remediation programs Orton Gillingham and Direct Instructional System for Teaching and Remediation (DISTAR) approaches – begin by simple phonetic units, and then blend these units into words and sentences Merrill program, and the Science Research Associates, Inc. (SRA) Basic Reading Program - introducing whole words first and then teach to break them down and recognize the sounds of the syllables and the individual letters in the word. Bridge Reading Program - teaches to recognize whole words through the use of visual aids and bypasses the sounding-out process. The Fernald method - teaching whole words with a tracing technique so that the child has kinesthetic stimulation while learning to read the words

38. SPECIFIC LEARNING DISORDER WITH IMPAIRMENT IN MATHEMATICS

39. Definition Mathematics disorder (dyscalculia) refers to impairment in the development of arithmetic skills, including but not restricted to computational procedures used to solve arithmetic problems and the representation and retrieval of basic arithmetic facts from long-term memory.

40. Problematic skills in mathematics disorder four groups of skills are poorly achieved  linguistic skills (understanding mathematical terms and converting written problems into mathematical symbols),  perceptual skills (the ability to recognize and understand symbols and order clusters of numbers),  mathematical skills (basic + , - , x, ÷ ), and  attentional skills (copying figures correctly and observe symbols correctly).

41. Etiology Psychological Factors Neurological Factors Genetic Factors Environmental Factors Emotional Factors

42. Psychological Factors  Core neuropsychological factor - impairment in number sense.  The term number sense is used to refer to two distinct constructs: (1) a biologically based nonverbal capacity to estimate numerosity (non-symbolic representation of numerical magnitude, such as arrays of dots) - property of the visual system; and (2) an acquired verbally based ability - through enculturation and formal schooling

43. Neurological Factors Inferior parietal sulcus plays a dominant role in numerical processing fMRI - children use frontal regions during calculation, whereas adults use in parietal areas. children may have to use attentional and working memory resources until they acquire adult-like levels of automaticity and functional specialization for mental arithmetic. MRI studies - decreased gray matter in the left parietal lobe. Moreover, calculation ability was found to be related to plasma taurine level in the neonatal period since taurine is important in neural development

44. Genetic Factors Family studies - 50 to 60 % of all siblings and parents of children with mathematics disorder also have mathematics disorder. To date, no specific genes for mathematics disorder/dyscalculia Environmental Factors Psychosocial adversity and schooling, and Affective factors - anxiety and motivation. Children from low-income households have a low level of number sense— because of their poor experience.

45. E m o t io n al F ac t o r s Math anxiety refers to increased physiological reactivity, negative cognitions, avoidance behavior, and substandard performance when presented with math stimuli. As math anxiety increases, working memory is compromised and math achievement declines. Math anxiety is common, particularly in females.

46. Signs of mathematics disorder   q u antita t i v e has difficulty with counting - may count on fingers d i f fi c ult y wit h m at h e m atic c o n c e p t s and r e a s o nin g , a n d c a n ’ t s o l v e problems switching to use the wrong sign midway through a complex problem, incorrect regrouping procedures, ( 6 x 4 ) + 3 misalignment of digits, and completing the arithmetic procedure in the wrong direction (e.g., left to right; top to bottom in order to subtract a smaller from a larger number). and poor comprehension of fractional concepts ( ¼ )

47. During the first 2 or 3 years of elementary school, a child with poor mathematics skill may just do it by relying on rote memory. But soon, as mathematics problems require discrimination and manipulation of spatial and numerical relations, a child with mathematics difficulties is affected. In older children (i.e., third grade and above), major impairments are evident in rapid retrieval of number facts (e.g., 6 × 7) and in solving more complex arithmetic problems.

48. Assessment Standardized measurement of intellectual function is necessary to make this diagnosis. The Keymath Diagnostic Arithmetic Test measures several areas of mathematics including knowledge of mathematical content, function, and computation. It is used to assess children in grades 1 to 6. Woodcock–Johnson Achievement Battery-III Test of Early Mathematical Abilities Teacher Academic Attainment Scale (TAAS)

49. Math anxiety may be assessed using child self-reported math anxiety scales • • (e.g., Math Anxiety Questionnaire [11 items]; Abbreviated Mathematics Anxiety Scale for Children [9 items]); Health numeracy in adults may be assessed using Subjective Numeracy Scale Test of Functional Health Literacy in Adults (s-TOFHLA) • • • Rapid Estimate of Adult/Adolescent Literacy in Medicine [REALM])

50. Treatment Psychoeducation about the disorder and its longer-term implication is an essential first step. Mathematics difficulties are best remediated with early interventions that lead to improved skills in basic computation. The presence of specific learning disorder in reading along with mathematics difficulties can impede progress; however, children are quite responsive to remediation in early grade school.

51. Effective educational techniques for children with mathematics disorder are those which incorporate reinforcement of acquired arithmetic skills, a concrete-to-abstract teaching sequence, think-aloud procedures (i.e., verbalization while problem solving), creative strategies and mnemonics for sequential problem-solving, Frequent monitoring of the student's progress, and teaching skills

52. Project MATH, a multimedia self-instructional training program • • • • Several promising computer-based software programs (e.g., Number Worlds; Number Race) have been developed. Problem-solving skills in the social arena also helps in mathematics. Behavioral strategies (e.g., relaxation training, systematic desensitization, visualization of successful math performance) have been found to be effective for math anxiety.

53. SPECIFIC LEARNING DISORDER WITH IMPAIRMENT IN WRITTEN EXPRESSION

54. Is a condition diagnosed in childhood characterized by poor writing skills that are significantly below for the child's age, intelligence, and education, and i n g r am m a r and cause problems with the child's academic success or other important areas of life. C o m p on e n t s o f wr i tin g d is o r d e r i n c l ud e p o o r s p e ll i n g , e r r o r s punctuation, and poor handwriting. Also called dysgraphia, spelling disorder and spelling dyslexia.

55. Spelling errors are among the most common difficulties for a child with a writing disorder. Spelling mistakes are most often phonetic errors; that is, an erroneous spelling that sounds like the correct spelling. Examples are: fone for phone, or beleeve for believe. In contrast with DSM 5, the ICD 10 has a separate category called specific spelling disorder.

56. Etiology Neuropsychological Factors Genetic Factors Perinatal Factors

57. Neuropsychological Factors Writing skills include both transcription and composition (text generation). Transcription writers transform the words they want to use into written (orthographic) symbols; it involves spelling and handwriting skills. It is based on phonological short-term memory Composition (text generation) – the act of constructing written text. Ideas are generated in memory and then transcribed onto the written page. It is based on verbal working memory. • Difficulties in any one area (e.g., transcription, listening or reading comprehension, working memory) can delay skill development and efficient functioning in another.

58. Genetic Factors Family studies - youth with impaired written expression have first-degree relatives with similar difficulties. Twin studies - the heritability of spelling deficits to be higher than the heritability of reading deficits. Molecular genetic studies – spelling disability - chromosome 15 orthographic skills - chromosome 6. Four candidate genes (DYX1C1 on 15q, KIAA0319 and DCDC2 on 6p, and ROBO1 on 3q).

59. Perinatal Factors Extreme prematurity (i.e., <28 weeks' gestation or birth weight of <1,000 g) - poor spelling, as well as with poor reading and mathematics. recent large-scale randomized trial - relationship between breastfeeding and children's cognitive development and academic attainment at age 6 years, particularly in reading and writing.

60. Clinical Features Avoidance of written work   O n l y a f e w w o r d s o r s e n t e n c e s i n t h e s a m e t i m e w h e n o t h e r s t u d e n t s p r o du c e s e v e r a l paragraphs Excessive problems in generating a text (output failure) E xc e ss i v e t e c h n i ca l e r r or s o f pun c t u a t i o n , g r a mm a r , w or d u s a g e , s e n t e n c e s t r u ct u r e , a n d paragraph structure fail to capitalize the first letter of the first word in a sentence Frequent omission of words in sentences or incomplete sentences

61.  Poor organization of written work (e.g., poor paragraph organization; poor cohesion within sentences)  Disordered and illegible handwriting (e.g. admixture of printing and cursive writing; inappropriate admixture of upper- and lower-case letters , inverted letters)  essential written activities such as notes taking is difficult – as it involves simultaneous listening, comprehending, retaining information, process new information, and summarizing the important points rapidly into a legible and useful format for subsequent review.

62. Common spelling problems Confusion of similar letters or sounds (e.g., “jumpt” for “jumped”; “caterpault” for “catapult”) Inability to select correct spelling from two plausible alternatives (e.g., successful/succesfull; necessary/necessery) Frequent use of nonpermissible letter strings (e.g., “egszakt” for “exact”; “freeeqwnt” for “frequent”) Same word spelled in different ways within one piece of written work

63. Standardized Tests for Assessing Written Expression Wechsler Individual Achievement test (WIAT-II) Test of Written Language (TOWL; 3rd edition) Test of Early Written Language (TEWL; 2 nd edition) Test of Written Spelling (TOWS; 4th edition) Test of Written Expression (TOWE)

64. Treatment A preventative approach of providing instruction in handwriting, spelling, and composition in primary grades, for children already at risk of reading delay is effective in improving these children's subsequent spelling and reading abilities. Explicit instruction in handwriting - directing attention to critical features of letters and on-task demands Other variables include sequence in which letters are introduced, paper position, and pencil grip

65. • Spelling can be improved by systematic spelling instruction that focuses on letter patterns (orthography) and opportunities to practice writing. • Writing involves teaching of three critical steps: Planning, writing the first draft, and revision of the draft. • The inclusion of mnemonics (e.g., P.O.W.E.R: Plan, Organize, Write, Edit, Revise; C-SOOP: Capitalization, Sentence structure, Organization, Overall format, Punctuation) provides an effective reminder to the sequence of processes and steps being taught.

66. COMORBIDITY Reading and mathematics disorder frequently occur comorbidly with language disorder. Children with language disorder have poor word knowledge, limited abilities to form accurate sentence structure, and impairments in the ability to put words together to produce clear explanations and • difficulties with grammar and syntactical knowledge. There are also high rates of comorbidity between reading impairment and mathematics impairment - up to 60 percent. communication disorders (primarily with mixed receptive-expressive language disorder), as well as with developmental coordination disorder.

67. 25 % of children with SLD may have comorbid ADHD. Same genetic factors contribute to both reading impairment and attentional syndromes. The major link appears to be between the inattention dimension of ADHD and RD. high rates of depressive moods and feelings of lack of control and poor self-esteem Oppositional Defiant Disorder, Conduct Disorders especially in adolescents. Genetic deficits (e.g., velocardiofacial syndrome, fragile X syndrome, Down syndrome, Williams' syndrome, Gerstmann's syndrome),

68. Differential Diagnosis A diagnosis of SLD is not usually made before the child is about 6 or 7 years old because evidence of failure to learn to read is required. Intellectual disability syndromes in which most skills, are below the achievement expected for a child's chronological age. Intellectual testing helps to differentiate. Inadequate schooling - can be detected by comparing a given child's achievement with classmates on reading performance on standardized reading tests. Hearing and visual impairments should be ruled out with screening tests. Impaired motor coordination, arising from developmental coordination disorder or neurological damage, may produce illegible handwriting, but in the absence of additional impairments in spelling and expression of thought in writing, a disorder of written expression is ruled out.

69. • often find it difficult to keep up with their peers in certain academic subjects, whereas they may excel in others. often leading to demoralization, low self-esteem, chronic frustration, and compromised peer relationships. increased risk of comorbid disorders, including attention-deficit/hyperactivity disorder (ADHD), communication disorders, conduct disorders, and depressive disorders. are at least 1.5 times more likely to drop out of school, approximating rates of 40 percent. Adults with are at increased risk for difficulties in employment and social adjustment. COMPLICATIONS

70. NGO found in 1992 remedial help and support to children spreading awareness Hosts learning centres in school in tamil nadu Conduct training for teachers

71. Su m m a r y DSM-5 combines the DSM-IV diagnoses of reading disorder, mathematics disorder, and disorder of written expression and learning disorder NOS into a single diagnosis: Specific learning disorder. Dyslexia is characterized by difficulties with inaccurate word recognition and poor spelling and decoding abilities resulting from a deficit in the phonological component of language. Mathematics disorder refer to impairment in the development of arithmetic skills, including computational procedures used to solve arithmetic problems and the retrieval of basic arithmetic facts from long-term memory. Disorder of written expression Is characterized by poor writing skills like poor spelling, errors in grammar and punctuation, and poor handwriting SLD could cause complications if not remedied earlier.

72. C o ncl u s i o n Intense and focused instruction may in fact alter the brain activation profiles observed in children with SLD. Thus, clinicians need to be aware that recommendations for placement in special education may not alone be sufficient to improve reading or arithmetic skills. Rather, they need to advocate for intense and focused instruction in each of the affected academic domains. Also, given the importance of literacy and numeracy skills in health, clinicians are advised to screen for health literacy and numeracy in all children.

73. R ef e r e n c e s Kaplan and Sadocks Comprehensive textbook of Psychiatry – 10 th edition Kaplan and Sadocks Synopsis of Psychiatry – 11 th edition Postgraduate Textbook of Psychiatry – Ahuja 3 rd edition Rutter’s child and adolescent psyhiatry – 6 th edition

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