SPECIFIC LEARNING DISABILITY

DEPARTMENT OF PEDIATRICS

1st FEBRUARY – 15th FEBRUARY

2025

ANKIT KUMAR
202001089
2021
NAME: ANKIT KUMAR
ROLL NO: 109
REGISTRATION NO: 202001089
SUBJECT: PEDIATRICS
BATCH: 2021
INTRODUCTION
What is a Specific Learning Disability (SLD)?
 Specific Learning Disability (SLD), also known as developmental learning disorder, is an umbrella
term for neurodevelopmental disorders. These are typically diagnosed in early school-aged children,
though diagnosis may occur later in adulthood.
 Specific Learning Disability (SLD) encompasses difficulties in accurate and/or fluent word
recognition, understanding the meaning of what is read, spelling, written expression, and/or
mathematical abilities. These difficulties are unexpected concerning the individual’s chronological
age and the provision of appropriate instruction.
 SLD is characterized by persistent impairment in at least one of the following areas: reading, writing
expression, arithmetic, or a combination thereof.
 SLD is a significant deficit in learning relative to what is expected based on age and intellectual
ability. Environmental factors or other psychiatric symptoms cannot fully explain this disease. A
child's academic performance is directly related to their overall health; SLD's academic decline is
specifically attributed to the neurodevelopmental disorder itself.
 Specific Learning Disability (SLD), sometimes called by other names such as word blindness,
dyslexia, alexia, dyscalculia, acalculia, dysgraphia, or agraphia, are disorders, not just difficulties that
disrupt the typical pattern of skill acquisition from early development.
 SLD is a potentially disabling condition that can interfere with a child's adaptation at school and in
society. Therefore, it's also considered a specific learning disability, a legal status providing access to
support and accommodations.
 SLD involves specific processing difficulties within the brain, unlike global difficulties seen in
intellectual disability (previously known as mental retardation). Individuals with SLD have trouble
perceiving what they see and hear and struggle to connect information from different parts of the
brain.

1)Psychiatric disorders
(depression, anxiety, autism
spectrum disorder)
Secondary SLD
Academic decline is a symptom
secondary to other conditions
1)Organic conditions (stroke,
Aetiology-Based Classification
encephalitis, meningitis,
of SLD
epilepsy)
Primary SLD
Academic decline directly results
from neurodevelopmental
disorders, not secondary
psychiatric disorders
Understanding the Neurological Basis of SLD
The process of learning involves sensory input (eyes, ears, touch), processing, storage, and retrieval of
information in the brain. Specific cognitive skills—focus, comprehension, memory—are essential for
reading, writing, and math. These are uniquely human abilities, making SLD specifically a human condition.

Diagnosis of SLD
Diagnosis involves gathering information from multiple sources:

1. Observations of the child. 5. Teacher reports.

2. Interviews with the child, siblings, and 6. Neuropsychological testing (may be used
parents. to aid in intervention strategies,
3. Family history. particularly helpful in obtaining disability
4. School records (notes, assignments, benefits in India)
exams).
To diagnose SLD, a persistent problem must be present despite reasonable interventions. This includes:

• Tier 1: Regular classroom instruction

• Tier 2: Classroom instruction plus small group supplemental intervention

• Tier 3: Individualized intervention

SLD is diagnosed only if the problem remains intractable despite these interventions.

The persistence of the learning difficulties is key to the diagnosis.

Reasons for Consultation Parents often bring children to doctors due to:

o Behavioural problems: Oppositional de ant disorder, conduct disorder, etc.

o Emotional problems: Depression, anxiety.
o Academic decline: Laziness, poor performance, trouble completing work, etc.

Schools may refer children because of the following:

o Academic underperformance. o Difficulties with reading, writing,

spelling, or math

Assessment Procedures
o Parental consent is essential. o Multiple assessment sessions may be
o Diagnosis and intervention take time needed to ensure accurate results,
(2-3 years for improvement). with breaks to prevent fatigue.
Assessment Components

The assessment process involves:

 Detailed history (complaints, behavioral/emotional problems, schooling history, family history).

 Behavioral observation.
 Mental status examination.
 Informal assessment of reading, writing, spelling, and arithmetic.
 Physical and neurological examination (including sensory assessment).
 Screening for comorbid conditions (ADHD, ODD, depression, anxiety).
 Gathering reports from the child's teacher.

Types of SLD Assessments Criterion-referenced tests:

 Scored based on pre-determined standards or criteria.
 Norm-referenced tests: Scored based on comparison to a norm group.

Norm-Referenced Tests Norm-referenced tests interpret scores based on a student's performance

relative to a peer group, not on absolute standards. This approach has advantages and disadvantages,
depending on factors like the student's native language and the test's validity and reliability (sensitivity
and specificity).

Assessing Cognitive Abilities and IQ

IQ Testing: Various standardized tests assess a child's intelligence level, including

 Binet-Kamit (BKT) Test
 Alliance Intelligence Scale for Indian Children (MISC)
 Batterson Intelligence Test

SLD Assessment Tools

 Wide Range Achievement Test

 Test of Written Language
 Restless Individual Achievement Test
 Kaufman Test of Educational Achievement
 Free Body Individual Achievement Test-Revised
 Neiman's Index for SLD: A useful tool for early identification of learning issues; it's a paper-pencil
test but has limitations (available in limited languages, age range 5-12 years).
 SLD Assessment Flowchart

SLD as per Indian Law

The Indian Rights of Persons with Disabilities Act (RPWD) of 2016 defines specific learning disability as:

A heterogeneous group of conditions involving a deficit in the processes of understanding or using spoken
or written language. This may manifest as difficulty with comprehension, speaking, reading, writing,
spelling, or mathematical calculations. Conditions included are perceptual disabilities, dyslexia, dysgraphia,
dyscalculia, dyspraxia, and developmental aphasia.
History & Origin
Year Milestone Key Figure(s)
1877 First identification of reading inability ("word blindness") Adolphe
Kussmaul
1887 Introduction of the term "dyslexia" Berlin
1932 Introduced the concept of comparing actual and expected achievement for Marion
assessment Monroe
1937 Differentiated SLD in children with average or above-average IQ; introduced Samuel Orton
multi-sensory training
1961 De ned dyslexia as an unexpected difficulty in learning school abilities; Samuel Kirk
introduced "specific learning disability"
1970 SLD appears in UK health and education policies N/A
1977 US Office of Education includes cognitive discrepancy between IQ and N/A
achievement in the SLD definition.

DSM Evolution of SLD

 DSM-I: Chronic brain syndrome
 DSM-II: Mild brain damage and ADHD
 DSM-III: Separated Academic Skills Disorder and ADHD
 DSM-IV & DSM-5: Differentiated reading, writing expression, and mathematics as key areas of
manifestation.

DSM-5 Criteria for SLD

The DSM-5 outlines four key criteria:

1. Persistent difficulties (at least six months) in at least one academic area despite targeted interventions.
These areas include:

 Reading (accuracy, fluency, comprehension)

 Writing (spelling, grammar, organization)
 Mathematics (number sense, calculation, reasoning)

2. Academic skills substantially below expected age, causing problems in school or daily life.

3. Difficulties begin during school-age years, though they may not be fully apparent until adulthood.

4. Difficulties are not due to other conditions (intellectual disability, vision/hearing problems,
neurological conditions, socioeconomic factors, or language difficulties).

Diagnostic Process: Diagnosis is based on observations, interviews with the child and parents, family
history, school reports (teacher reports, homework, tests), and possibly neuropsychological testing.
Neuropsychological tests aid in creating a tailored intervention plan and disability certification.
TYPE OF IMPAIRMENT DESCRIPTION
IMPAIRMENT IN Difficulties with word reading accuracy, fluency, and comprehension; spelling
READING accuracy is also a factor, often considered dyslexia.
IMPAIRMENT IN Difficulties with spelling accuracy, grammar, punctuation, clarity, and organization
WRITTEN EXPRESSION of written expression; this is dysgraphia.
IMPAIRMENT IN Difficulties with number sense, memorization of arithmetic facts, accurate
MATHEMATICS calculation, and mathematical reasoning; this is dyscalculia.

Note: Multiple types may be present.

DSM-5 also specifies severity:

1. Mild: Some difficulties in one or two areas, with potential for compensation.
2. Moderate: Significant difficulties requiring specialized teaching and accommodations.
3. Severe: Severe difficulties affecting multiple areas, requiring intensive, ongoing specialized teaching.

Differential Diagnosis
Several conditions may mimic SLD. It's crucial to differentiate SLD from:

1. Borderline intelligence or intellectual 7. Discrepancy between mother tongue and

disability schooling medium
2. ADHD (Attention Deficit Hyperactivity 8. Inadequate schooling facilities
Disorder) 9. Lack of social support
3. Oppositional defiant disorder 10. Hearing or visual impairment
4. Conduct disorder 11. Neurological disorders (e.g., myopathy,
5. Autism Spectrum Disorder writer's cramp)
6. Absenteeism (due to substance use,
medical, or psychiatric conditions)
Co-occurrence and Comorbidities
SLD frequently co-occurs with other disorders. A meta-analysis of 51 studies (2022) in the Journal of Child
Psychology and Psychiatry revealed:

 Children with SLD have higher rates of both internalizing (e.g., depression, anxiety) and externalizing
(e.g., ADHD) disorders than their peers.
 Language disorders show a stronger association with internalizing problems than dyslexia.
 Approximately 70% of children with SLD have at least one other diagnosable psychiatric condition.

COMORBIDITY IS THE RULE, NOT THE EXCEPTION. This can lead to school dropout, legal issues, substance abuse,
suicidal ideation, and other serious problems.

Internalizing disorders are characterized by inward-directed emotional distress, while externalizing

disorders manifest as disruptive behaviors directed outward.

o Anxiety disorders: 20-30% o Conduct disorder: 6%

o ADHD: 10-60% o Autism spectrum disorder: 6%
o Depression: 33% o Language disorder: 55-70%

Risk Factors for SLD

1. Male gender 4. Family History: Mental illness, SLD (genetic
2. Prenatal/Maternal Factors: Poor prenatal component) In parents, caregivers, or
care, poor maternal nutrition, labor child
complications (e.g., asphyxia), low Apgar 5. Chronic Illness
score, low birth weight, pre-term birth, 6. Social/Environmental Factors
maternal education 7. Language Delay
3. Congenital Anomalies: Birth defects

Management and Remedial Measures for SLD

A key principle in managing SLD is to minimize the disruption to the child's life. Interventions should be
prioritized:

o School-based accommodations and modifications.

o Home-based support (if necessary).
o Clinic-based or institutional rehabilitation as a last resort

Remedial measures are processes designed to help children acquire age-appropriate skills necessary
for learning. These measures are rehabilitative and particularly relevant for children with
neurodevelopmental problems. They are not a one-time x but rather an ongoing process. Key
characteristics:

1. Maybe an individual or small group (ideally one-on-one)

2. Typically conducted at school or home (rarely at a clinic)
3. Sessions last 45 minutes to 1.5 hours, 2-3 times per week
4. May continue for 2-3 years Important
5. Don't be discouraged by a lack of immediate progress; development takes time
The primary goal of education remains consistent for all children.

SLD Subtype Associated Difficulties Interventions:

Reading Reading fluency, spelling Phonological training, letter-sound training, phonics
(Dyslexia) accuracy, reading accuracy instruction, vocabulary building, oral language
comprehension improvement, guided oral reading.
Writing Written expression, Motor skills training, orthographic training (letter
(Dysgraphia) organization, grammar retrieval), and higher-order skill training (planning,
accuracy organization, execution, proofreading).
Mathematics Number sense, Number syntax training, split instruction, verbalization,
(Dyscalculia) mathematical reasoning, real-world problem-solving strategies (games, shopping
fluent calculation activities)

Accommodations adjust how a child learns without altering the expected outcome.

Examples of accommodations include

 a slower class pace  Animation-based instruction

 Extra classes  Providing notes
 Use of technology (laptops, tablets,  Extra time on assessments
touchpads), multi-sensory teaching
methods
In contrast, Modifications change the learning expectations themselves. The process may remain the same,
but the outcome is altered. This involves lowering expectations or creating different standards for children
with disabilities.

Examples of modifications include:

 Extra time on tests  Exemptions from certain subjects (e.g.,

 Use of a scribe algebra, a second language)
 Multiple-choice tests only  Reserved seating or job opportunities
 Exemption from spelling penalties

Future Challenges in SLDs

 Lack of standardized screening tools across the country and languages.
 Need for cultural adaptation of assessment instruments.
 Lack of standardized remedial measure kits.
 Shortage of human resources for assessment and treatment

Conclusion
o SLD is a heterogeneous neurodevelopmental disorder with subtypes (reading, writing, math).
o High rates of comorbidity with other conditions are common.
o Early intervention is crucial to mitigate the substantial costs associated with SLD
o Minimize displacement of the child from regular schooling.
o Remedial measures should be implemented in school and at home.
o Severe cases may necessitate clinical intervention and specialized training outside the classroom.
CASE STUDY
Introduction
Anaisha Subba is a 6-year-old female child residing in Pakyong East Sikkim.
Respondent Sunita Raman is her caretaker and accompanies her to the hospital for
her Physiotherapy sessions. She attests that Anaisha was adopted by her parents
from the hospital. Her parents are Bankers. She has been undergoing physiotherapy
sessions for the last 5 years.

Chief complaints
1. Presenting complaint – inability to walk even at the age of 30 months
2. Current complaint – inability to climb stairs without support and run, instability while
walking, frequent falls

History of present Illness

The child was adopted at birth, and limited prenatal, birth, and early developmental
history are available. According to the adoptive parents, the child exhibited
significant developmental delays from an early age. Key milestones were delayed as
follows:

- Motor Development:
- The child did not walk independently until 30 months of age.
- Currently, at 6 years old, the child is unable to run, jump, or climb stairs without
assistance.
- Fine motor skills are also delayed, with difficulties in tasks such as buttoning
clothes.

- Speech and Language Development:

- Speech delays were noted
- Current speech is limited to Jargon speech
- The child has difficulty expressing needs and understanding complex instructions.

- Social and Emotional Development:

- The child exhibits challenges in social interactions, including difficulty making eye
contact, limited interest in peers, and preference for solitary play.

- Cognitive Development:
- Cognitive delays are evident, with the child struggling with age-appropriate
problem-solving, memory, and learning tasks. (cannot differentiate colors)
- The child attends school (UKG) as well as the Child Rehabilitation unit at CRH
Past Medical History:

- Congenital Heart Disease (as per Respondent)

- No history of significant illnesses, hospitalizations, or surgeries.
- Vaccinations are up to date.

Developmental History:

- Gross motor delays: walked at 30 months, yet to run.

- Fine motor delays: Difficulty with grasping objects, self-feeding, and dressing.
- Speech delays: limited vocabulary and sentence formation at present.
- Social delays: Limited interaction with peers

Family History:

- Limited information available due to adoption.

Social History:

- Lives with adoptive parents

- Attends school (UKG)
- Receives physical therapy.

Review of Systems:

- General: No fever, weight loss, or fatigue.

- Neurological: No seizures, loss of consciousness, or abnormal movements.
- Musculoskeletal: Difficulty with gross motor skills, no reported pain or deformities.
- Speech/Language: Limited vocabulary, difficulty expressing needs.
- Behavioral: difficulty with transitions, limited social interaction.

Treatment
Promotion of Reactive strategies (Ankle, Hip)
Postural control in standing
Treadmill training
Functional mobility Training
SMC Activation with and without weights
General Examination:

1. Appearance:
- The child appears underweight for age.
- Posture: slouched
- Gait- unsteady

2. Vital Signs:
- Heart Rate: 80 bpm (normal for age).
- Respiratory Rate: 16 breaths/min (normal for age).
- Blood Pressure: 120/80 mmHg (normal for age).
- Temperature: 38.5 °C (afebrile).

3. Hydration and Nutrition:

- Hydration status: Well-hydrated
- Nutritional status: Adequate

4. Skin:
- No rashes, bruises, or abnormal pigmentation noted.
- Skin turgor: Normal.

5. Lymph Nodes:
- No palpable lymphadenopathy.

6. Dysmorphic Features:
- No obvious dysmorphic facial features or congenital anomalies were noted.

Systemic Examination:

1. Neurological Examination:
- Mental Status:
- Alert but with limited interaction.
- Poor eye contact.
- Difficulty following commands.
- Cranial Nerves:
Intact (no obvious deficits noted).
- Motor Examination:
- Muscle bulk: Normal for age.
- Muscle tone: Hypotonic
- Muscle strength: Reduced in lower extremities (unable to run or climb stairs).
- Reflexes: Deep tendon reflexes (DTRs)- Normal
- Coordination and Balance:
- Poor coordination
- Unable to stand on one foot or hop.
- Sensory Examination:
- Grossly intact to light touch and pain (no sensory deficits noted).
 - Gait:
- unsteady
- Unable to run or climb stairs.

2. Musculoskeletal Examination:
- Joints:
- No swelling, tenderness, or deformities noted.
- Full range of motion in upper and lower extremities.
- Spine:
- No scoliosis or kyphosis.
- Limbs:
- No contractures or limb length discrepancies.

3. Cardiovascular Examination:
- Heart sounds: S1 and S2 normal, no murmurs, rubs, or gallops.
- Peripheral pulses: Palpable and equal in all extremities.

4. Respiratory Examination:
- Breath sounds: Clear bilaterally, no wheezing, crackles, or rhonchi.
- Chest expansion: Symmetrical.
- No signs of respiratory distress.

5. Abdominal Examination:
- Soft, non-tender, no distension.
- No organomegaly or masses palpable.
- Bowel sounds: Normal.

6. Genitourinary Examination:
- Normal external genitalia (no abnormalities noted).
- No signs of infection or structural abnormalities.

7. Speech and Language Assessment:

- Limited vocabulary.
- Difficulty forming sentences.
- Poor articulation.

8. Behavioral Observations:
- Limited social interaction.
- Poor eye contact.

Follow-Up:

- Regular follow-up with the primary care provider and specialists.

- Reassessment of developmental milestones regularly.
- Engage and coordinate with the child’s school to accommodate their needs.