1. LEARNING DISABILITIES
EMERGING TRENDS
Dr. Pawan Sharma
pawan60@gmail.com

2. • Evolution of concept
• Concept and approaches
• Epidemiology
• Pathophysiology
• Assessment and Management
• Prognosis
• Issues Indian Context
• Conclusion

3. • Evolution of concept
• Concept and approaches
• Epidemiology
• Pathophysiology
• Assessment and Management
• Prognosis
• Issues Indian Context
• Conclusion

4. EVOLUTION OF CONCEPT
1877
• Kussmaaul proposed a term “word blindness” or caecitas
verbalis for an acquired loss of words and introduced visual
analogy
1887
• Berlin first used the term “dyslexia” in his monograph
referring to acquired loss of reading ability
1892
• Dejerine deduced lesion in medial and inferior portion of left
occipital lobe could lead to dyslexia- “brain letter box”
1896
• Pringle Morgan was first to note a case of dyslexia
1917
• Hinshelwood defined word blindness as pathological
condition caused by disorder of visual centers of brain and
caused difficulty in interpreting written language

5. EVOLUTION OF CONCEPT
1937
• Orton (regarded as father of Dyslexia society) observed
children with reading problems had near average or above
average IQ
1962
• The term “learning disability” appeared in print (Kirk)
1977
• US passed a law stating all school must provide special
education to the child with LD. IQ discrepancy formula given
1985
• Between 1985 to 2000 several authority gave different
definitions for LD
1990…
• Advances in the research – neurobiology and genetic

6. EVOLUTION OF CONCEPT
• Earlier understanding of LD was more in terms of medical model
– Explanation in terms of brain damage or brain dysfunction
• Absence of hard evidence lead to development of the educational
framework for defining from 1960s
– Emphasis on discrepancy
– Visuo- motor problem
• From 1980s onwards US National Joint Committee on LD
formulated the concept involving all the previously concerned
discipline
• 1990 onwards more emphasis on the dimensional nature of
problem rather than categorical
– Adopted more by researchers (yet to be adopted by
practitioners)
2 major factors that have emerged
• Life span approach
• Language based problem
Pratibha Karanth, 2003

7. • Evolution of concept
• Concept and approaches
• Epidemiology
• Pathophysiology
• Assessment and Management
• Prognosis
• Issues Indian Context
• Conclusion

8. CONCEPTS
• Disorders interfering with the acquisition and use of one or more of
the following academic skills: oral language, reading, written
language, mathematics
NJCLD, 1988
• These disorders affect individuals who otherwise demonstrate at
least average abilities essential for thinking or reasoning
• Learning Disorders are distinct from Intellectual Developmental
Disorders
Larry B. Silver,2001

9. CONCEPTS
UK
Learning disability includes the presence of:
• Significantly reduced ability to understand new or complex
information, to learn new skills (impaired intelligence)
• Reduced ability to cope independently (impaired social functioning)
• Started before adulthood, with a lasting effect on development
Eric emersion 2010

10. CONCEPTS
• DSM (DSM-III), the issue of problems with learning was first addressed
“Academic Skills Disorders” AXIS II
• Motor and language difficulties also addressed under “Motor Skills
Disorders” - category for fine motor/handwriting difficulties
• “Communications Disorders” - categories for Receptive Language and for
Expressive Language Disorders
• “Specific arithmetical retardation” – ICD 9 and “Developmental arithmetic
disorder”- DSM III
• Developmental expressive writing disorder – DSM III

11. CONCEPTS:ICD Vs DSM
DSM 5 has Specific Learning Disorder as a single overall diagnosis
incorporating deficits that impact academic achievement
Criteria describes shortcoming in general academic skill
Detailed specifier for reading, mathematics and written expression
Both require evidence of a substantial discrepancy between scores on
reading achievement test and measured intelligence

12. CONCEPTS
Types :
• Dyslexia
• Dyscalculia
• Dysgraphia
Associated deficits and disorders:
• Auditory Processing Deficit
• Visual Processing Deficit
• Non-Verbal Learning Disabilities
• Executive Functioning Deficit
National center for learning disability,2014

13. APPROACHES
• Difference between
aptitude and
achievement
• Difference between
IQ and achievement
test scores
Discrepancy
• Multiple domains
• Reading,
mathematics ,
written expression,
language
Heterogeneity
• No sensory disorder,
mental deficiency,
emotional disturbance
• No economic disadvantage,
linguistic diversity or
inadequate instructions
exclusion
Individuals with Disabilities Education Act (IDEA),2004
No change in this discrepancy approach since 1977 when first approved
by US law

14. APPROACHES- STATIC MODELS
Ability
achievement
discrepancy
Difference
between
intellectual ability
and performance
No difference in
identification with
other model
Low achievement
model
Student
performing below
a certain
threshold
Doesn’t facilitate
whether the child’s low
achievement is
proportionate to the
ability
No distinguish high
ability student with
average achievement
Intraindividual
discrepancy
model
Uneven profile of
cognitive
measures
Over
identification
Kavale 2001

15. APPROACHES
CRITICISM
• With a low IQ score it is difficult to show an even lower reading test
score: introduces a bias against diagnosing dyslexia in less able
children
Miles and Haslum (1986)
• Delay in intervention until student’s achievement is low
• Delayed intervention might result to refractory to intervention
• Even criticized as “wait to fail” model
• Overidentification of students who are disadvantaged, ethnic
minority, display oppositional behavior

16. APPROACHES
RESPONSIVENESS TO INTERVENTION AS DEFINING MODEL:
• Universal screening of all students for reading difficulties in the
early school years
• Placement in early intervention programs
• Students can be identified with LD if they maintain deficient
achievement, do not adequately respond to increasingly intense
instructions
Fletcher, 2004

17. APPROACHES
RESPONSE TO INTERVENTION- ADVANTAGES
• Shifting of focus from eligibility to concerns about providing
effective instruction
• No waiting for students to meet IQ-discrepancy criteria (wait to fail)
to identifying students who need intervention as early as possible
and providing it immediately
• Not dependent on teacher referral that could be disproportionate
Douglas Fuchs, 2006

18. • Evolution of concept
• Concept and approaches
• Epidemiology
• Pathophysiology
• Assessment and Management
• Prognosis
• Issues Indian Context
• Conclusion

19. EPIDEMIOLOGY
National centre of learning disabilities

20. EPIDEMIOLOGY
• Lifetime prevalence of specific learning disorders (SLD) in age group
from 3 to 17 years of age is 9.7%
– Those with special health care needs (28%)
– Typically developing children (5.4%)
• 2.5 million public school students , 5% of all students in public
schools—were identified as having learning disabilities in 2009 in
US
National center of learning disabilities, 2014
• Reading disability accounts for 80-90% of all learning disabilities
• Boys> girls
(Lerner et al, 1989; Altarac et al ,2007)

21. EPIDEMIOLOGY:INDIA
STUDY N Urban/ rural Place Tools RESULT
Yadav et al, 2008 N=800 Rural Allahabad
School
Teachers opinion
Achievement
records
2.25%
Vijayalaxmi , 2009 N=1134 Urban Bangalore
School
NIMHANS
battery
15.17%
Mogasale et al,
2011
N=1134 Urban Bangalore,
school
NIMHANS
battery
15%
Choudhary et
al,2012
N=500
class 3-5
urban Bikaner
school
Dyslexia
Assessment
Questionnaire
10.25%
Dhanda and
Jagawat, 2013
N=1156 Rural Jaipur
School
IPS questionnaire 12.8%
Arun et al, 2013 N=2402
Class 7-
12
Urban Chandigarh
school
NIMHANS
battery
1.58%
Variability may be due to
• Rural urban
• Teacher screening only
• Language differences
• Socio economic status
• Teacher interview plus performance
• Methods of assessment
• ?Geographical variation

22. EPIDEMIOLOGY
National center of learning disabilities,

23. CORE PROBLEMS
• Receptive language- difficulty to process speech
sounds
• Visual perception defects-misinterpretation of
words
INPUT
• Sequencing
• Abstraction
• Organization
INTEGRATION
• Working: Information fragment into full concept
• Short term: information recall
• Long term: metacognitive skills like studying ,
inability to recall
MEMORY
• Language problems
• Motor problems
OUTPUT
Turnbull et al, 2004

24. MANIFESTATIONS
READING
• Slow, hesitant word
by word reading
• Reading without
punctuation
• Mirror reading, word
guessing
• Omission
substitution,
addition of words
• Understanding, recall
and drawing
inference
WRITING
• Avoiding or slow
writing
• Awkward pencil
holding
• Poor handwriting,
spelling, size
inconsistency, mixing
small and capital
letters
• Transposition, mirror
writing, add or omit
letters in words
MATHEMATICS
• Longer time
• Mistakes in sums
involving 0
• Difficulty in keeping
tenth, hundredth or
thousand place
• Carry over or
borrowing problem
• Difficulty in word
problems

25. ASSOCIATED PROBLEMS
BEHAVOURAL
• Laying blame on
teachers
• Making excuses for
bad behavior
• Exhibiting “I give
up” attitude
• Avoiding
confrontation about
school
Social
• Poorly accepted by
friends
• Greater risk for
social alienation
from teachers and
classmates
• Less social activity
• Impulsive answers
• Inappropriate
answers
• Get bullied
Emotional
• Remain aloof
• Feeling low
• Anger and
frustration
• Poor self esteem
• Receive a more negative assessment of social skills difficulties
• Poor self-esteem, frustration, and other barriers to developing social skills
• Lead to behavioral problems
Forness and Kavale,1996
MOTOR INCORDINATION
Among 137 children with LD , 50.4% of the children performing below the 15th
percentile on the Movement assessment Battery(balance coordination, manual
dexterity, ball skills etc.)
Vuijk et al, 2011

26. COMORBIDITIES
? Shared etiologic and neurocognitive risk factors
ADHD
Language
Impairment
Speech
Sound
Disorder
Learning
disability
ADHD, SSD, and LI are all
likely to be apparent
earlier and can thus
indicate a child’s
risk for later reading
problems
Pennington et al 2009

27. COMORBIDITIES
• Willcutt et al, 2000
• N=209 twins with reading disability
• n-=192 without RD
• DSM-III Diagnostic Interview for Children and Adolescents, Parent
Report Version
• Child self-report version of the Diagnostic Interview for Children
and Adolescents

28. COMORBIDITIES
STUDY SAMPLE TOOLS RESULTS
Margari et al
2013
448 Italian
children
7-16 yrs.
• DSM IV TR
• Standardized
diagnostic tests
for
neuropsychologic
al and
psychopathologic
al evaluation
Total Comorbidity % -58.3%
ADHD-33%
Anxiety disorder-28.8%
Mood disorder -9.4% Language
disorder 11%
Motor coordination disorder
17.8%
Gallegos et
al, 2012
120 Mexican
children with LD
and 120 without
LD
9 to 12 years old
• LD via school
records
• Spence
Children’s
Anxiety Scale
• Children’s
Depression
Inventory
Anxiety –23.3% VS 11.5%
Depression-32% VS 18%

29. COMORBIDITIES
The median LD
prevalence rate
across the 17
ADHD Studies
was 31.1%,
Control:
median
prevalence of
8.9%
The prevalence
rate of ADHD in
LD a median
prevalence of
38.2% across
studies
Control: 5%
DuPaul and Stoner (2003) reviewed 17 studies conducted between 1970s to 1990s that
reported the percentage of students with
1982- 19931978-1993

30. • Publications from the past decade (i.e., 2001–2011) were
reviewed
• Rates of LD in students with ADHD ranged from 8% to 76% of
students (Median = 47%, M = 45.1%)
Dupaul et al 2012

31. • Evolution of concept
• Concept and approaches
• Epidemiology
• Pathophysiology
• Assessment and Management
• Prognosis
• Issues Indian Context
• Conclusion

32. ETIOPATHOGENESIS-THEORIES
THEORY EXPLAINATION LIMITATIONS
Phonological Specific impairment in
the representation,
storage, and/or retrieval
of the speech sounds
Inability to explain the
occurrence of sensory
and motor disorders in
dyslexic individuals
The rapid auditory
processing theory
failure to represent short
sounds with fast
transition would cause
difficulty in response to
the acoustic events with
phonemic contrast like
/ba/ vs /da/
Same
Visual theory Abnormality in the
magnocellular layers of
lateral geniculate nucleus
Failure to replicate the
visual findings
Scerri and Schulte Korne, 2010

33. ETIOPATHOGENESIS-THEORIES
THEORY EXPLAINATION LIMITATIONS
Cerebellar theory • Motor control, speech
articulation,
automatization of
repetitive task like driving
reading
• Brain imaging studies also
show anatomical,
metabolic and activation
differences
• Outdated view of the
motor theory of speech
• Cases of normal
phonological
development despite
severe dysarthria or
apraxia of speech
The magnocellular (auditory
and visual) theory
Combines both auditory
and visual theories
General impairment in
magnocellular pathways
Visual, auditory and tactile
sensory modalities
affected
• Each theory can only explain a proportion of individuals with
dyslexia
• Possibility that each theory may account for different sub-sets
of dyslexia brought about by different etiologies
Scerri and Schulte Korne, 2010

34. ETIOPATHOGENESIS-THEORIES(3 TIER)
Biological
• Left hemisphere
disconnection
cognitive
• Phonological
deficit
• Poor Graph-
phoneme
knowledge
Behavioral
• Poor reading
• Poor phoneme
awareness
• Poor STM
• Poor naming
speed
ENVIRONMENTAL FACTORS
Teaching method
Cultural factors
Socio economic factors
Frith, 1999

35. ETIOPATHOGENESIS-THEORIES(3 TIER)
Biological
• Frontal
temporal
area
Cognitive
• Phonological
deficit
• Attention
deficit
• Poor
inhibitory
control
• Poor graph-
phoneme
Behavioral
• Poor
planning
• Poor
achievement
• Poor reading
• Poor naming
skill
ENVIRONMENTAL FACTORS
Teaching method
Cultural factors
Socio economic factors
Frith, 1999

36. ETIOPATHOGENESIS-THEORIES(3 TIER)
Biological
• Magnocellular
abnormality
cognitive
• Slow temporal
processing
• Auditory and
visual deficit
• Phonological
deficiit
Behavioral
• Poor tone
• Poor reading
• Poor
coordination
• Poor speech
development
ENVIRONMENTAL FACTORS
Teaching method
Cultural factors
Socio economic factors
Frith, 1999

37. ETIOPATHOGENESIS(LANGUAGE)
• 30 dyslexic children from urban India(New Delhi ) English medium
school
• Hindi and English word reading task
• A significantly greater accuracy for Hindi word reading than English
(42% vs 30%)
Language Phonetic Orthographic
Hindi 65% 15%
English 57% 35%
• Reading strategies are affected in part by the orthographic transparency of
the language
• Hindi- Shallow(spelling-sound correspondence is direct)
• English- Deep(reader must learn the arbitrary or unusual pronunciations of
irregular words.)
Ashum Gupta, 2006

38. NEUROBIOLOGY
• First reported by Dejerine in 1891 that damage to (angular gyrus)
resulted in variable degree of impairments in reading and writing
• Autopsy
– Symmetrical Plannum Temporale - triangular structure on the
superior surface of the temporal lobe inside the Sylvian fissure
(SF) and it is a region of the cortex that falls within the
Wernicke’s area( left hemisphere)
– cortical malformations in the form of neuronal ectopias,
architectonic dysplesias (focally distorted cortical
architecture) and microgyria (abnormal infoldings)
– Disorganized magnocellular layers of visual pathway and smaller
medial geniculate nucleus in left of auditory pathway
SO Wajuihian ,2011

39. NEUROBIOLOGY
• MRI studies
– Studies divided in the symmetry of PT
– higher degrees of asymmetry of the temporal
lobes
– No consistent finding
SO Wajuihian ,2011

40. NEUROBIOLOGY -FUNCTIONAL
STUDY SAMPLE
SIZE
TASK FINDING
Corina et al, 2000 8 case 8
controls
Phonological and
lexical auditory
judgement
Activation in right than left in
left temporal gyrus(phon)
Less activity in b/l middle
frontal gyrus and more activity
in left orbital frontal cortex
(lexical)
Shulz et al, 2008 16 case 13
control
Identical sentence
reading
Decreased activation of frontal
and inferior parietal regions of
LH
Richards et al, 2008 18 case 21
controls
Phoneme
mapping task
Greater functional
connectivity between left
inferior fronytal gyrus to right

41. NEUROBIOLOGY -FUNCTIONAL
STUDY SAMPLE
SIZE
TASK FINDING
Richlan et al, 2010 15 cases 15
controls
Phonological lexical
decision task
Dysfunction in regions of
left occipito-temporal
accompanied by absent
responsiveness in
phonological regions of
inferior frontal gyrus
Rimrodt et al, 2009 15 case 15
control
Sentence
completion to word
recognition
areas associated with
linguistic processing
More activation

42. NEUROBIOLOGY -FUNCTIONAL
Meta analysis
7 original studies on functional abnormalities in the dyslexic
Activation Likelihood Estimation (ALE)
Underactivation
inferior parietal, superior temporal, middle and inferior temporal
fusiform regions of the left hemisphere
Overactivation
inferior frontal gyrus
primary motor cortex
anterior insula
• Contrary to previous findings of compensatory activation of right
hemisphere and posterior region
Richan et al, 2009

43. Left Inferior frontal
gyrus
(Activates during
phoneme/word
production/ articulation
)
Left Parietal-
temporal
(word analysis or
phonological
decoding )
Left occipital-
temporal
(word form
recognition )
Compensatory
increase
Hypoactivation
No Corresponding Increased activation – RIGHT
SIDED Posterior regions as opposed to previous
meta analysis

44. NEUROBIOLOGY ANATOMICAL
• White Matter decreases in the left frontal and parietal portions of
the arcuate fasciculus
• Gray matter density decrease in dyslexics in the key area of
functional underactivation (left medial temporal gyrus)
• Family study – the grey matter changes present from beforehand/
as a risk factor
• Altered connectivity in specific WM tracts ( left superior
longitudinal fasciculus) compromise the acquisition of language and
cognitive skills important for reading
Peterson and Pennington, 2012

45. GENETICS - PATHOPHSYSIOLOGY
The genetic architecture underlying dyslexia is complex and
multifactorial
9 susceptibility genes named DYX1 to DYX9 with various candidate
genes
No genome wide association studies till date
Two or more
genes
contribute to
the phenotype
Polygenecity
Same disorder can
be caused by
multiple origins in
different individual
Heterogeneity
Scerri et al, 2010

46. GENETICS - PATHOPHYSIOLOGY
• Studies of post-mortem dyslexic brains
– cerebrocortical neuronal migration disorders ranging from
small heterotopia to focal microgyria
• All the Dyslexia candidate genes play a central role to a
signaling network involved in neuronal migration and neurite
outgrowth
abnormal
neuronal
migration
anomalous
brain
oscillations
Auditory
signal
disturbance
Poor
phonological
processing
Scerri et al, 2010

47. ETIOLOGY
• Literary
outcomes
• Reward and
punishment
• provision of
teaching,
• cultural attitudes
• socio-economic
factors
• Underlyin
g Process
• Genetic
• Neuro-
Anatomic
al
Biological Cognitive
Behavioral
Environm
ental
The overall etiology can be summarized as the interplay of different factors

48. • Evolution of concept
• Concept and approaches
• Epidemiology
• Pathophysiology
• Assessment and Management
• Prognosis
• Issues Indian Context
• Conclusion

49. ASSESSMENT
AUTHORS NAME CONTENT AREAS REMARKS
Kapur, John,
Rozario and
Oommen, 1991
NIMHNS
Index for
SLD
Level1-
preacademic
skills 5-7 yrs
of age
Level 2- class
1-7
Conjunction with MISIC
Areas: Attention, reading,
spelling, perceptuo-
motor, visuo-motor
Memory, arithmetic
Validity and
reliability defines
English and Hindi
Cut off provided
Konanthambigi
and shetty,
2008
Scale Developed at
special
education
cell of SNDT
women
university
Using behavior checklist
For teachers for
identification
Validity not defined
Yadav and
Agrawal, 2008
Learning
disability
scale
19 questions
in 5 areas
Verbal disability, oral
attention disability,
writing disability,
mathematical
computation disability,
written attention
disability
Short scale
Easy administration
Validity not known

50. ASSESSMENT
STUDY BATTERY CONTENT REMARKS
Mehta M and
Sagar R, 2003
AIIMS SLD
battery
Bender Visuo-Motor Gestalt test
for motor co-ordination
Reading (using NCERT book
text)
Expression - verbal and written
Comprehension
Arithmetic
Non verbal SLD
No cut off
Qualitative
scale
Apart from these Indian scales there are other questionnaire
• Diagnostic reading scales
• Reading Acquisition Profile in Kannada (RAP-K) in Kannada (Prema1998)
• Behavioral checklist for screening the learning disabled (Swarup and
Mehta ,1991)
• Wechsler Objective dimension(1993)
• Woodcock Johnson 3 achievement(2001)
• Wide Range achievement test
• Schonell spelling test

51. ASSESSMENT
Step 1: Gather the history
Step2: Standardized assessment
Step 3: Behavioral Observation during
assessment

52. ASSESSMENT
Step 1: Gather the history
Step2: Standardized
assessment
Step 3: Behavioral Observation
during assessment
• Developmental
• Educational
• Emotional and behavioral
• Classroom observation of learning behavior
• Attention
• Organization
• Homework
• Test taking behavior
• Social interaction with peers

53. ASSESSMENT
Step2: Standardized assessment
Step 3: Behavioral Observation
during assessment
• Cognitive ability
• Malin's Intelligence scale for Indian children
• Wechsler Intelligence Scale for children IV
• Stanford Binet
• Information processing
• Auditory and visual
• Memory and executive functioning
• Achievement
• Reading
• Writing
• Mathematics

54. ASSESSMENT
Step 3: Behavioral Observation
during assessment
• Level of anxiety
• Fatigue
• Handwriting, pencil grip, pressure while writing
• Ability to sustain attention during assessment
Integrated approach involving audiologist, ophthalmologist, neurologist,
speech therapist, occupational therapist, pediatrician and psychiatrist

55. SN PROFESSIONAL ROLE ASSESSMENT
1 The Pediatric
Neurologist
detailed clinical history and thorough physical examination
• exclude medical cause
• identify behavioral causes
2 Counsellor • Rule out any environmental deprivation due to poor home or
school environment, or any emotional problem due to stress at
home or at school
3 Clinical
Psychologist
• Conduct the standard intelligence test to determine IQ and rule
out intellectual disability
• Assess the learning disability in different areas using Battery of
tests
• Assess: Emotion and Behavioral problems the child is facing
Comorbidities, Other Psychological issues
• Assess: Neuropsychological deficits
4 The Special
Educator
• Further assess and address the issues accordingly
5 Child
Psychiatrist
• Rule out diagnosis of other conditions which cause poor school
performance, viz., "isolated" ADHD, depression, conduct disorder,
and oppositional defiant disorder

56. MANAGEMENT
SN PROFESSIONALS MANAGEMENT
1 Clinical Psychologists • Psychoeducation
• Provide psychotherapy for the
emotional problems, anxiety,
behavioral problems, poor self
esteem
• Address the neuropsychological
problems
2 Psychiatrists • Provide psychotherapy
• Medications if required for the
comorbidities
3 Special educators • Major role in providing training and
special education as per need of the
child

57. INTERVENTION
Fox et al, 2009

58. INTERVENTIONS(READING)
• High interest/low vocabulary materials
• Multisensory method
• Programmed reading, Remedial reading drills, Neurological Impress
method
Fernald method(whole word
approach): 4 steps
• select a word in flash card, trace
with fingers, say it loud
• Repeat without tracing
• Repeat without writing
• Learn new word from the last
word
Gillingham method(Phonic
method):
• One letter in card spoken by
teacher
• Repeated by student many times
• Expose card and ask
• Teacher makes sound
represented by letter and ask
the letter

59. INTERVENTIONS(WRITING)
• Handwriting practice
• Fading model
– Match upper and lower case
– Make association like p=Flag
• Cover and write method
• Spelling games: blocks, scrabbles
• Multisensory like in reading creating distinct visual image and
habit formation through repetition
• Showing student his wrong spelling and correcting it in front

60. INTERVENTIONS(MATHEMATICS)
• Number work exercises
– Classification: grouping of objects according to their
distinguishing character
– Ordering and sequencing on the basis of properties
– One to one correspondence: distributing pencils, matching
school bags
• Multiplication addition etc with beads, blocks or straws
• Weave math into daily life

61. • Evolution of concept
• Concept and approaches
• Epidemiology
• Pathophysiology
• Assessment and Management
• Prognosis
• Issues Indian Context
• Conclusion

62. PROGNOSIS
National center of learning disabilitie

63. PROGNOSIS
National center of learning disabilities, 2014

64. PROBLEMS IN ADULT
• Systemic review
• 33 studies 318 factors extracted and classified in International
Classification of functioning disability and health (ICF)
• Adult dyslexic came out with the problems in the domains as :
– Negative feelings and emotions like frustration insecurity, anger,
stigmatized, inferiority feeling
– Difficulty in organizing and planning
– Difficulty solving problems
– Difficulty in reading or writing
– Difficulty acquiring and keeping job
– Poor support and negative attitude at work- Fear of demotion
All the domains of life personal , environment , social affected by
dyslexia Beer et al, 2014

65. • Evolution of concept
• Concept and approaches
• Epidemiology
• Pathophysiology
• Assessment and Management
• Prognosis
• Issues Indian Context
• Conclusion

66. ISSUES INDIAN CONTEXT
Certification of
SLD
• No uniform
national guidelines
for diagnosis and
assessment of
severity and
certification of SLD
Difficulties in creating
uniform assessment
tools:
• Multiple language spoken in
India
• Awareness problems in
parents and teacher
• differences in quality of
teaching , school environment,
student teacher rat
Facilities
• Not recognized as a
disability in the PWD Act
1995
• Provision like extra time
, change in the subject
etc. by CBSE board
• No consensus among
the boards
25 item questionnaire regarding
knowledge of LD in regular
school, pre service and special
school teachers
• Minimum knowledge in pre
service teacher
• 70% supported LD as a
problem.(Saravanabhavan ,
2010)
50 parents of LD(semi
structured questionnaire)
Only 16% aware of cause, 66%
felt some kind of education
needed and only 11% knew it
was a life long
disorder(Karangde, 2007)
Abuse of certificates in urban
areas
• Ambitious parents
• Demand certificates
even if children are dull
average in intelligence
• Instances where
children asked to make
deliberate mistakes
• School authorities
• Concerned about
results by giving facility
of provisions
• Untrained professionals
• Training as a business
Mehta, M, 2011

67. Right of Children to Free and Compulsory
Education Act, 2009 (RTE Act)
Pros
• Makes education for children
6-14 yrs. of age free and
compulsory
• No child held back, expelled
or required to pass a board
examination until completion
of class standard VIII
• Preventing the stress,
maladjustment or behavioral
problems related to
detention
Cons
• Late referral of the children
to learning Disability clinic
• LD children would be
diagnosed late
• Crucial time period for
"remedial education" i.e. lost
opportunity to overcome
Disability will be lost
• Psychological trauma to the
child and to the parents
Unni,2012

68. Right of Children to Free and Compulsory
Education Act, 2009 (RTE Act)
Pros
• Makes education for children
6-14 yr of age free and
compulsory
• No child held back, expelled
or required to pass a board
examination until completion
of class standard VIII
• Preventing the stress,
maladjustment or behavioral
problems related to
detention
Cons
• Late referral of the children
to learning Disability clinic
• Dyslexic children would be
diagnosed late
• crucial time period for
"remedial education" will be
lost i.e. lost opportunity to
overcome Disability
• Psychological trauma to the
child and to the parents
Amendment that mandates that children who are getting poor
marks/grades, irrespective of their class standard, are referred
to a Learning Disability clinic to undergo an assessment of their
academic difficulties
Unni,2012

69. PATHWAYS TO CARE
• N=50 cases of specific learning disability
• 8-16 yrs
• Pathways to Care Instrument devised by Goldberg and Huxley
Mean time 1st care 1.08 yrs
Mean time tertiary care 3.39 yrs
Presentation
comorbidity
Poor academics
14%
64%
Chakraborty et al, 2014

70. TIME LAG IN DIAGNOSIS
• 50 children diagnosed with SLD and/or ADHD
• Hospital based
• Average age of diagnosis: 11.36
• Average age at which children’s symptoms noticed: 5.55yrs
• Delay: 6 yrs.
• 30% already had class retention
• 40% had aggressive or withdrawn behavior
• Significant lag in detection and diagnosis
• Children with SLD and co-occurring ADHD need to be
identified at an early age to prevent poor school
performance and behavioral problems
Karande et al , 2007

71. FACTORS FOR IDENTIFICATION
• Educational longitudinal study
• N=16000 from 750 schools
Positive predictors of
identification
• Language minorities i.e.
foreign language as first
language
• The students enrolled in ELS
• Male
• Non white population
Negative predictors of
identification
• Student enrolled in US schools
after primary education
Shifrer et al, 2010

72. FACTORS FOR RECOGNITION
Difficulties in India
• Multi language and multicultural setting
• 18 different orthographic forms of language
• 3 language system in education State, Hindi and English
• Lack of tools of assessment in different language
S Rama, 2000

73. • Evolution of concept
• Concept and approaches
• Epidemiology
• Pathophysiology
• Assessment and Management
• Prognosis
• Issues Indian Context
• Conclusion

74. CONCLUSION AND WAY FOREWARD
• There has been a progressive shift in the understanding of learning
disability as a disorder and last decade has seen good number of
research in this field
• There have been criticism in the definitional issues from past that
continue to happen in present
• Children with learning disability face problems in multiple facets of
life (with or without comorbidities) even when they become adult –
early intervention warranted
• Despite a lot of research the it hasn’t been possible to formulate
causal mechanism – role of neurobiology and genetics present but
exact mechanism not known

75. CONCLUSION AND WAY FOREWARD
• In Indian prospective research are limited even to determine the
overall prevalence
• Lack of tools in different language and lack of grading system has
made assessment difficult
• Legislative support for the dyslexic children throughout the country
via proper policy and facilities is warranted
• Further research in this field warranted