Specific learning disorder is a neurodevelopmental disorder

1. SPECIFIC LEARNING
DISABILITY
Presenter: KRITI JAIN
MPhil CP I YEAR (2020-’22)
Gwalior Mansik Arogyashala
Date: 28 September 2021

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

3. History
o 1877 Rudolph Berlin coined the term dyslexia
o 1896, British physician W. Pringle Morgan - first to describe reading difficulty
in a 14- year-old boy
o 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.
o 1960s Gerstmann described Gerstmann syndrome
o 1962 The term “Learning Disability” was given by Samuel Kirk
o 1970s - pinpointed the cause as deficits in phonological processing.

4. Terminology
o 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”).
o Phonemic awareness: awareness that there are discrete speech sounds
(phonemes) in speech.
o Phonological awareness: awareness that spoken language comprises discrete
units – words, syllables and phonemes.
o Phonological coding: Translating the letters of a written word into speech
patterns to identify the word and gain access to its meaning.
o Orthography: The representation of the sounds of a language by written or
printed symbols. (e.g., Incredible - / n kr d b( )l/ )ɪ ˈ ɛ ɪ ə|)

5. DSM
o 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.
o Learning deficits in reading, written expression, and
mathematics in the DSM-5 are designated using specifiers

6. DSM-V
Specific Learning disorder
o 315.00 With impairment in reading (specify if with word reading
accuracy, reading rate or fluency, reading comprehension)
o 315.1 With impairment in mathematics (specify if with number
sense, memorization of arithmetic facts, accurate math reasoning)
o 315.2 With impairment in written expression (specify if with
spelling accuracy, clarity or organization of written expression)
Specify current severity: Mild, Moderate, Severe

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

8. ICD-11
6A03 Developmental learning disorder
o 6A03.0 Developmental learning disorder with impairment in
reading
o 6A03.1 Developmental learning disorder with impairment in
written expression
o 6A03.2 Developmental learning disorder with impairment in
mathematics
o 6A03.3 Developmental learning disorder with other specified
impairment of learning
o 6A03.Z Developmental learning disorder, unspecified

9. Psycho-social effects of SLD
o Decreased self-esteem
o Demoralization
o Frustration
o Peer and adults relations are affected
o Bullying
o Severe SLD may make it painful for a child to succeed in school,
often leading to a sense of shame and humiliation because of their
continuing failure and subsequent frustration.

10. EPIDEMOLOGY
o SLD of all types affects approximately 10 % of youth.
o SLD occurs two to three times more often in males than in females.
o Reading and written expression disorder are more common in boys
and mathematics disorder is more in girls.
o At least 75% of all individuals identified as having SLD have
reading disorder.

11. o The prevalence of a disorder of written expression and
mathematics disorder is about 6 percent of school-aged children.
o 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.

12. Pre-requisite for assessment
o Clinical interview
o Mental Status Examination
Axis (Rutter’s) Description
Axis 1 Psychiatric Disorder
Axis 2 Developmental delays
Axis 3 Intelligence
Axis 4 Physical health
Axis 5 Psycho-social stressors

13. Intelligence Assessment
o As per Gazette of India document, 2018 –MISIC/ WISC III/ WISC
IV is to be administered before NIMHANS SLD Index battery.
o Since MISIC does not have norms for children above 15, WASI- II
(India)/ WAPIS/ BKT may be used.
o Child must obtain an IQ of 85 or above.

14. SPECIFIC LEARNING DISORDER WITH
IMPAIRMENT IN READING

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

16. Definition
o According to Lyon and co-workers, 2003,
“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.”
o Dyslexia - Greek origin, with a meaning “impaired word.”

17. Etiology
Neurological Factors
o • fMRI - show a distinct brain activation profile during reading.
o • Basic word reading activates three systems in the left side of
the brain :
(1) an anterior system in the left inferior frontal region - phoneme
production (vocalizing words silently or out loud);
(2) a left parieto-temporal system - analyzing the written word
(3) a left occipito-temporal system - automatic word recognition

18. Genetic Factors
o RD is highly familial and heritable.
o Up to 50 % of children of parents with RD and 50 % of siblings of a child
with RD may have the disorder.
o Twin studies - high concordance rates for RD. Genetic factors account for 69
to 87 % and 13 to 30 % is due to environmental factors.
o Molecular genetic studies of RD have reported several susceptibility loci on
chromosomes 1p, 2p, 3p, 6p, 11p, 15q, 18p, and Xq27.3.
o Chromosome 1p – common susceptibility locus for both reading disorder and
inattention dimension of ADHD

19. Cognitive Theory
Phonological Theory
o 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.
o At the neurological level, there is a dysfunction of left hemisphere perisylvian
brain areas that support phonological representation.
o Double-deficit hypothesis - phonological and naming-speed deficits
o Naming-speed deficits - slow rate in the recognition and retrieval of the names
of symbol. E.g.: naming colors, letter or objects. Double deficit leads to a more
profound form of RD
o Triple-deficit model - The addition of an orthographic deficit to the double-
deficit model. Individuals with orthographic deficits have difficulty in recalling
written words.

21. Rapid Auditory Processing Theory
o Auditory deficit in the perception of short or rapidly varying
sounds.
o Studies demonstrated that individuals with RD perform poorly
on auditory tasks (e.g., frequency discrimination) and exhibit
abnormal neurophysiological responses to various auditory
stimuli.
o 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.

22. Visual/Magnocellular Theory
o Most common and influential theories of dyslexia
o Emphasizes a visual contribution to reading problems
o Proposed visual problems include unstable binocular fixations,
poor visual tracking, abnormalities in perception of visual motion
and poor contrast sensitivity.
o Mechanism - disruption of the magnocellular pathway
o 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.

24. Signs of Reading Disorder
o Kindergarten
o Lack of interest in playing games with language sounds (e.g.,
repetition, rhyming), trouble learning nursery rhymes
o Failure to recognize letters in their own name
o Trouble remembering names of letters, numbers, or days of the
week
o Unable to recognize phonemes (e.g., does not know which of the
set of words “dog,” “man,” “car” starts with same sound as “cat”)

25. o Primary Grades (Grades 1–3)
o Receives reports of “not doing well in school”
o Unable to read one-syllable words, such as “mat” or “top”
o Problems in connecting sounds and letters (e.g., “big” for
“got”)
o Difficulty in sequencing numbers and letters

26. o Middle Grades (Grades 4–6)
o Mispronounces or skips parts of long words (e.g., says “conible” for
“convertible” and “aminal” for “animal”)
o Confuses words that sound alike (e.g., “tornado” for “volcano”)
o Trouble remembering dates, names, telephone numbers
o Gets the first part of word correct, then guesses wildly (e.g., reads “clover”
as “clock”)
o Poor comprehension, terrible spelling
o Trouble completing homework or tests on time, fear of (refuses) to read
aloud, avoids reading

27. o High School, College, Work
o Slow, effortful reading of single words and connected text
o Trouble pronouncing multi-syllable words, frequent need to
reread material to understand
o Avoids activities that demand reading (reading for pleasure,
reading instructions)

30. Assessment
o Psychoeducational testing, is critical in determining these
deficits.
o The reading subtests useful are
• Woodcock-Johnson Psycho-Educational Battery- Revised
• The Peabody Individual Achievement Test-Revised
• Test of Word Reading Efficiency (TOWRE)
o NIMHANS index for SLD (1992, 2019)
Level I -Younger students (5-7 years)
Level II -Older students (8 to 12 years)

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

36. Treatment
o Typically carried out in education settings or specialized psychology clinics
o The psychiatrist’s primary role is to instigating pharmacological or
psychological treatment for coexisting mental health problems
o Remediation - focus on direct instruction that leads a child's attention to the
connections between speech sounds and spelling.
o After individual letter- sound associations have been mastered, larger
components of reading such as syllables and words are targeted.
o 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
o 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.
o 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.
o Bridge Reading Program - teaches to recognize whole words through the use of
visual aids and bypasses the sounding-out process.
o 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:
o Linguistic skills (understanding mathematical terms and converting written
problems into mathematical symbols),
o Perceptual skills (the ability to recognize and understand symbols and order
clusters of numbers),
o Mathematical skills (basic + , - , x, ÷), and
o Attentional skills (copying figures correctly and observe symbols correctly).

41. Etiology
Psychological Factors
o Core neuropsychological factor - impairment in number sense.
o The term number sense is used to refer to two distinct constructs:
 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
 an acquired verbally based ability - through enculturation and formal
schooling

42. Neurological Factors
o Inferior parietal sulcus plays a dominant role in numerical processing
o 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.
o MRI studies - decreased gray matter in the left parietal lobe.
o Moreover, calculation ability was found to be related to plasma taurine level
in the neonatal period since taurine is important in neural development

43. Genetic Factors
o Family studies - 50 to 60% of all siblings and parents of
children with mathematics disorder also have mathematics
disorder.
o To date, no specific genes for mathematics disorder/dyscalculia

44. Environmental Factors
o Psychosocial adversity and schooling, and
o Affective factors - anxiety and motivation.
o Children from low-income households have a low level of
number sense— because of their poor experience.

45. Emotional Factors
o Math anxiety refers to increased physiological reactivity,
negative cognitions, avoidance behavior, and substandard
performance when presented with math stimuli.
o As math anxiety increases, working memory is compromised
and math achievement declines.
o Math anxiety is common, particularly in females.

46. Signs of mathematics disorder
o Has difficulty with counting - may count on fingers
o Difficulty with mathematic concepts and reasoning, and can’t solve quantitative
problems
o Switching to use the wrong sign midway through a complex problem
o Incorrect regrouping procedures ( 6 x 4 ) + 3
o Misalignment of digits
o 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)
o Poor comprehension of fractional concepts ( ¼ )

47. o 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.
o But soon, as mathematics problems require discrimination and
manipulation of spatial and numerical relations, a child with
mathematics difficulties is affected.
o 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
o Standardized measurement of intellectual function is necessary to make this
diagnosis.
o 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.
o Woodcock–Johnson Achievement Battery-III
o Test of Early Mathematical Abilities
o Teacher Academic Attainment Scale (TAAS)
o 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])

49. Treatment
o Psychoeducation about the disorder and its longer-term
implication is an essential first step.
o Mathematics difficulties are best remediated with early
interventions that lead to improved skills in basic computation.
o 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.

50. o 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

51. o Project MATH, a multimedia self-instructional training program
o Several promising computer-based software programs (e.g., Number
Worlds; Number Race) have been developed.
o Problem-solving skills in the social arena also helps in mathematics.
o 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. Definition
Is a condition diagnosed in childhood characterized by poor writing
skills that are significantly below for the child's age, intelligence,
and education, and cause problems with the child's academic
success or other important areas of life.

55. o Components of writing disorder include poor spelling, errors in
grammar and punctuation, and poor handwriting.
o Also called dysgraphia, spelling disorder and spelling dyslexia
o Spelling errors are among the most common difficulties for a
child with a writing disorder.
o Spelling mistakes are most often phonetic errors; that is, an
erroneous spelling that sounds like the correct spelling.
o Examples are: fone for phone, or beleeve for believe.
o In contrast with DSM 5, the ICD 10 has a separate category
called specific spelling disorder.

56. Etiology
Neuropsychological Factors
o Writing skills include both transcription and composition (text generation).
o 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
o 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.
o Difficulties in any one area (e.g., transcription, listening or reading
comprehension, working memory) can delay skill development and efficient
functioning in another.

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

58. Perinatal Factors
o Extreme prematurity (i.e., <28 weeks' gestation or birth weight
of <1,000 g) - poor spelling, as well as with poor reading and
mathematics.

59. Clinical Features
o Avoidance of written work
o Only a few words or sentences in the same time when other students
produce several paragraphs
o Excessive problems in generating a text (output failure)
o Excessive technical errors of punctuation, grammar, word usage, sentence
structure, and paragraph structure
o Failure to capitalize the first letter of the first word in a sentence
o Frequent omission of words in sentences or incomplete sentences
o Poor organization of written work (e.g., poor paragraph organization; poor
cohesion within sentences)

60. o Disordered and illegible handwriting (e.g. admixture of printing and cursive
writing; inappropriate admixture of upper- and lower-case letters, inverted
letters)
o 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.

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

65. Assessment
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; 2nd edition)
• Test of Written Spelling (TOWS; 4th edition)
• Test of Written Expression (TOWE)

66. Treatment
o 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.
o Explicit instruction in handwriting - directing attention to critical features of
letters and on-task demands
o Other variables include sequence in which letters are introduced, paper
position, and pencil grip
o Spelling can be improved by systematic spelling instruction that focuses on
letter patterns (orthography) and opportunities to practice writing.

67. o Writing involves teaching of three critical steps: Planning,
writing the first draft, and revision of the draft.
o 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.

68. COMORBIDITY in SLD
o 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.
o There are also high rates of comorbidity between reading impairment and
mathematics impairment - up to 60 percent.
o 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

69. o Communication disorders (primarily with mixed receptive-
expressive language disorder), as well as with developmental
coordination disorder.
o High rates of depressive moods and feelings of lack of control
and poor self-esteem
o Oppositional Defiant Disorder, Conduct Disorders especially in
adolescents.
o Genetic deficits (e.g., velocardiofacial syndrome, fragile X
syndrome, Down syndrome, Williams' syndrome, Gerstmann’
syndrome)

70. Differential Diagnosis
o 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.
o Intellectual disability syndromes in which most skills, are below the
achievement expected for a child's chronological age. Intellectual testing helps
to differentiate.
o Inadequate schooling - can be detected by comparing a given child's
achievement with classmates on reading performance on standardized reading
tests.

71. o Hearing and visual impairments should be ruled out with screening
tests.
o 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.

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

73. Documents required before certification
o Detailed case history and Psychiatrist’s opinion
o Detailed report of assessments – intelligence and learning abilities
o Summary sheet mentioning areas of disability and severity (signed by
Clinical Psychologist)
o School report (signed by teacher, sealed by school)
o Pediatric neurologist’s opinion
o Occupational therapist’s opinion (if dysgraphia is present)
Medical board conducts a meeting (Multi disciplinary team) to decide on issuing the certificate

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

76. References
o Gelder, M., Andreasen, N., Lopez-Ibor, J., & Geddes, J. (2009). New Oxford Textbook of
Psychiatry (2 volume set) (2nd ed.). Oxford University Press.
o Rutter’s Child and Adolescent Psychiatry by Rutter, Sir Michael, Bishop, Dorothy, Pine,
Daniel, Scott, S (2010) Paperback (5th Edition). (2021). Wiley-Blackwell.
o Sadock, B. J., Sadock, V. A., & Md, R. P. (2014). Kaplan and Sadock’s Synopsis of Psychiatry:
Behavioral Sciences/Clinical Psychiatry (Eleventh ed.). LWW.
o Sadock, B. J., Sadock, V. A., & Md, R. P. (2017). Kaplan and Sadock’s Comprehensive
Textbook of Psychiatry (2 Volume Set) (10th ed.). LWW.
o World Health Organization. (1992). The ICD-10 Classification of Mental and Behavioural
Disorders: Clinical Descriptions and Diagnostic Guidelines (1st ed.). World Health
Organization.

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