Symposium on NeurodeveloPmental Disorders-II

Approach To Learning Disability

Madhuri Kulkarni, Sarika Kalantre, Shubhangi Upadhye, Sunil Karande and Sanjeev Ahuja

Division of Neurology, Dept. of Pediatrics, Lokmanya Tilak Municipal GeneralHospital and Lokmanya
Tilak Municipal Medical College, Sion, Mumbai, Maharastra, India

Abstract. Learning disabilities (LD) is one of the important causes of poor academic performance in school going
children. Learning disabilities are developmental disorders that usually manifest during the period of normal
education. These disabilities create a significant gap between the true potential and day to day performance of an
individual. Dyslexia, dysgraphia and dyscalculia denote the problem related to reading, writing and mathematics.
Perinatal problems are certain neurological conditions, known to be associated with LD; however, genetic
predisposition seems to be the most probable etiological factors. Evaluation of a child suspected to be having LD
consists of medical examination, vision and hearing test analysis of school performance. The psycho-behaviour
assessment and education testing are essential in the process of diagnosis. The experienced persons in the field
of LD should interpret the results of such tests. With Individualized Remedial Education Plan (IEP) most children
leam to cope up with disability and may get integrated in a regular steam. [Indian J Pediatr 2001; 68 (6) : 539-546]

Key words : Learning disabilities; Dyslexia; Remedied education

Children who have difficulties in reading and writing having LD.

fail to show the expected progress in the regular Learning disability refers to a d i s o r d e r that
schools. They usually get low grades in school tests and interferes with one's ability to store, process or produce
become a source of great anxiety for parents and information) Lea_mi~ disabilities are seen in children
teachers. Most children having learning disabilities as well as in adults. The impairment may be so subtle
present with poor scholastic performance, especially in that it may go undetected throughout the life. These
the middle secondary school. Besides learning disabilities create a gap between the true potential and
disabilities (LD) there are other causes of school-failure day to day productivity and performance.
seen in children. Lower levels of intelligence account
Definition : National Joint Committee for Learning
for a majority of failures. The children with intellectual
Disabilities (NJCLD) 1988z
functioning at "low-normal" ( 80 89) and
"borderline" ( 70 - 79) IQ show poor performance due Learning disabilities is a generic term that refers to a
to difficulties in understanding abstract concepts. heterogeneous group of disorders manifested by
Children with primary or secondary attention deficits significant~difficulties in the acquisition and use of
have poor concentration and difficulties in learning. skills such as listening, speaking, reading, writing,
Chronic medical conditions leading to school reasoning or mathematical abilities. These disorders
absenteeism is another important factor causing poor are intrinsic to the individual, are presumed to be due
performance in school. Emotionally disturbed children to central nervous system dysfunction and may occur
show academic failures. Emotional insecurity may be across the life span of the individual. Problems in self
due to the factors related to home or school regulatory behaviour, social perception and social
environment. A change of school can bring failure in an interaction may exist with learning disability, but do
insecure child due to exposure to a new atmosphere, not by themselves constitute a learning disability.
which at times may be a hostile environment. Also, it Although learning disability may occur concomitantly
should be noted that failure is a common cause of with other handicaps or with extrinsic influences, they
failure. A child who has failed once, develops feelings are not the result of these conditions or influences.
of inferiority and low self esteem. These factors need to The concept of learning disability was recognized
be carefully looked for in a child suspected to be the world over as a federally designated handicapping
condition. The field now has grown to encompass
Reprint requests : Dr. Madhuri Kulkarni, Dept. of Pediatrics, almost half of all the students receiving special
LTMG Hospital, Sion, Mumbai-400 002, Maharastra. education services in the United States.The school

Indian Joumal of Pediatrics, Volume 68---June, 2001 539

 Madhurl Kulkami et al

teachers and educators are confronted with the Also, factors such as previous head trauma,
problem of understanding how best to educate these plumbism, otitis media, meningities, seizures and its
children, who fail to learn despite an average or above treatment have been shown to be associated with
average intellectual capacity. The learning disabled learning disability. Chronic medical conditions like
individual possesses a unique set of characteristics asthma may interfere with learning through
which needs to be recognized for an effective absenteeism and or concomitant emotional concerns.
educational intervention. Rutter et al (1970)s documented an increase incidence
There are three types of learning disabilities that are of learning and behavioural problems in children with
commonly described.3 They are as follows : epilepsy. Farwell et al (1990) 6 suggested that
phenobarbital may affect the cognitive function in 2-3
1. Dyslexia : The word Dyslexia is derived from the years old children given the medication to prevent
Greek word "dys" meaning difficult and "lexia" febrile seizures and may lead to learning problems.
meaning words or vocabulary. Commonly The exact aetiology of learning disability is difficult
interpreted as difficulty in reading, dyslexia to prove, nevertheless past medical problems do
denotes a language disorders affecting reading, contribute to the development of learning disability
spelling, speaking and listening. and may even compound the disability by frequent
2. Dysgraphia : The term refers to an unexpected school absenteeism. The exact cause and effect
difficulty in learning to write. relationship would be difficult to prove.
The neurologic disorders like Neurofibromatosis 1,
3. Dyscalculia : The term refers to a disorder
Tuberous sclerosis and children treated with cranial
affecting mathematical reasoning and
irradation have a higher frequency of learning
calculations.
disability and the ratio of nonverbal to verbal L.D. is
reversed, compared with the general population. 7
CLINICAL EVALUATION PROCEDURE
A. Birth History
An accurate diagnosis with a complete description of a
Information regarding pregnancy and birth is
child's learning problem is not possible without a
important to note as factors like prematurity, low birth
thorough evaluation. The evaluation must identify the
weight history of perinatal asphyxia may lead to
academic areas that present problems, the factors that
sequelae of learning disability. Lilenfield and Pasama-
contribute to the problems, the available strengths for
nick (1960)8proposed a range of factors like prolonged
compensation and the extent of non-academic
labour, malpresentation, cord around neck leading to
difficulties.
hypoxic ischemic injury to the brain responsible for
The clinical evaluation consists of the following : learning disability in children.
In a series conducted by Davie et al (1972),9Dunn et
9 Medical assessment including history with spedal
a/(1971)1~it was consistently reported that Appropriate
emphasis on events at birth, developmental
milestones, educational performance and socio- for Gestational Age (AGA) children faired better
cultural background of family. The detailed academically than Small for Gestational Age (SGA)
physical and neurological examination should be babies. Thus, prematurity and LBW may be considered
performed. The vision and hearing test should be as important contributing factors for the development
of learning disability.
undertaken to detect the sensory defidts if present.
9 Analysis of school performance : school reports, B. Development History
history of failures/condonement and assessment
of the child's behavior in school. The milestones in d e v e l o p m e n t of speech and
9 Assessment of General Cognitive Functioning as language are very important for evaluation of a child
measured on standardized tests for intelligence. with a suspected learning disability.
9 Assessment of Achievement Level - as measured Language Delay
on educational tests.
9 Assessment of associated behavioral and social Many children with learning disabilities have history
problem if any. suggestive of delay in language development. They fail
to use words, sentences or phrases at an appropriate
MEDICAL HISTORY age or continue to speak in single words. Many of these
children also have articulation problems which may
Events around the perinatal period are extremely persist for a long period through the school age. This
important in children with developmental disabilities? delay or imprecision of language use is often carried

540 Indian Joumal of Pediatrics, Volume 68--June, 2001

 Approach to teaming Disability

over to learning letters of the alphabet and to reading. (1959)13and Bakwin (1973)14showed that concordance
Language deficits of reading, writing and spelling have rates for monozygotic versus dizygotic twins was
been described as developmental disturbances, higher.
reflecting an immature nervous system, u It was also
observed that learning disabled children had slow SOCIAL HISTORY
maturation of language skills, especially reading.
Socioeconomic status as well as education of parents
Therefore, delayed onset of speech may be a symptom
should be recorded. It has been reported that factor like
of a language disorder in the presence of otherwise
inferior intellectual level, lack of motivation, lack of
normal developmental milestones. environmental stimulation and parental indifference
Motor Co-ordination to the child's scholastic attainments interfere with the
school achievements. A child belonging to an
Children with learning disability may be slow to sit,
unpriviledge class may show lower performance due
walk or run and may have a general clumsiness.
to these environmental factors. Also, understanding of
Activities such as walking, jumping, catching are often
socioeconomic status of the family is of great help in
delayed. Children with LD tend to be clumsy and planning the interventional program for a child having
awkward on the playground and are unable to
learning disability.
perform simple physical exercises like toe touching or
balancing. PHYSICAL EXAMINATION
However, it may be noted that in most learning
disabled children, the motor milestone may be normal Primary learning disability itself has no specific signs
but and they often demonstrate motor clumsiness and found on physical examination. However, physical
awkward finger movements which are related to the examination including detailed neurologic
difficulties in motor co-ordination. examination is important to detect neurological defidts
or other handicapping condition in such a child.
Bladder Control
Neurocutaneous markers like hypopegmented-
Generally, bladder control is not delayed in learning macules (ash leaf macules), periungle filromas or
disabled children, but a few may have associated shagreen patches, multiple cafe-au-lait spots may be
enuresis. It was observed that children with enuresis seen in children with learning disability.
were found to have developmental delays twice as The presence of dysmorphic features like epicanthal
oftenJ2The aforementioned link between enuresis and folds, slanting palpebral fissures, microcephaly and
developmental delay, would suggest that there is a polydactly may be an indication of chromosomal
common underlying maturational factor that makes defects or associated M.R.
learning disabled children, more vulnerable to develop
enuresis as well as behavioural disturbances. NEUROLOGICAL EXAMINATION

SCHOOL HISTORY The clinical neurologic examination is undertaken

chiefly to assess the motor co-ordination abnormalities
In depth interviews with parents discussing the that may be present in children with learning
problems in the school should be documented in detail. disability.
History of past failures, condonements, behavioural A gross neurologic examination is generally normal
problems, child's behaviour in classroom and the in learning disabled children. Some children
teacher's perception of the child behaviour should be occasionaly demonstrate difficulty in tandem walking
noted. The child's report-card to assess the or an abnormal Finger-Nose Test. Mild forms of
performance in individual subject is very useful in the neurologic signs like asymmetry of reflexes,
process of diagnosis of learning disability. asymmetric gait or an awkward posture observed in
some children with LD suggest neurologic deficit or
FAMILY HISTORY immaturity of the CNS.
The soft, substle or neuromaturational signs are the
A history of language difficulties or scholastic features, that change over time. These may be present
problems in the parents or other family members in normal young children, but when present in older
should be inquired in each case suspected to be having children indicate neurologic immaturity. Following
LD A strong association between a positive family soft signs of motor functions, directionality and body
history and occurance of LD has been documented in space concept should be looked for in a child suspected
many studies. The studies conducted by Herman to having LD.

Indian Journal of Pediatrics, Volume 68--June, 2001 541

 Madhud Kulkami et el

Motor Functions Directionality

a) Repetitive finger tapping/dysdiadochokinesis- the Left - right confusion - inability to d i s t i n g u i s h
ability to carry out rapid alternating movement on between left and right.
each side is tested in turn.Inability to d o these Delayed if confusion is persistent beyond the age of
m o v e m e n t s is c o n s i d e r e d n o r m a l in c h i l d r e n 12 years.
y o u n g e r t h a n 11 years, b u t is i n d i c a t i v e of
n e u r o l o g i c i m m a t u r i t y w h e n p r e s e n t in older Body - Space Concepts
children.
Finger gnosis - ability to recognize, identify and
b) T a n d e m gait - ability to m a s t e r f o r w a r d a n d
differentiate fingers when touched separately. Delayed
background gait. Abnormal when not achieved by
if confusion is present b e y o n d 7 ~ years. It is found
7 years of age.
that children with LD may have the more number of
c) Sequential opposition of fingers to thumb. m i n o r neurological signs as c o m p a r e d to n o r m a l
children. H o w e v e r , most signs d i s a p p e a r b y 11-12
d) Mirror movements (synkinesia)
y e a r - o l d a n d o l d e r c h i l d r e n w i t h LD m a y n o t
e) Motor awkwardness. demonstrate these signs. Shaywitz and Shaywitz is

Tast~ 1. Pre-School Characteristics

9 Significant delay in development of speech.
9 Delay in development of fine motor skills.
9 Difficulty in pronouncing words. Child often has difficulty separating / sequencing sounds in words (cimena for cinema)
or blending sounds (Kirket for Cricket)
9 Difficulty or slowness to add new vocabulary words
9 Unable to recall the right word
9 Inabih'ty to rhyme by age 4 years.
9 Difficulty in tying shoe laces
9 Confusion in directionally words and space concepts, left versus right, over versus under, before versus after.
9 Lack of dominant handedness (switches from right hand to left hand between tasks or even while doing the same task)
9 May have trouble learning the alphabet, numbers, day of the week, colors, shapes.
9 May have difficulty telling and / or retelling a story in the correct sequence.

TAB~ 2. Primary School Characteristics

9 Has difficulty decoding single words ( reading single words in isolation ).
9 May be slow to learn the connection between letters and sounds e.g. the sound 'K' goes for both ' C in cat & 'K' in kite.
9 May confuse small words - at - to, said - and, does - goes.
9 Makes typical reading and spelling errors such as :
Letter reversals - d for b as in dog for bog.
Word reversals - tip for pit.
Inversions - m and w , u and n.
Transpositions - felt and left.
Substitutions - house and home.
9 May transpose number sequences and confuse arithmatic signs. (+-x/=)
9 May have trouble remembering facts.
9 May be slow to learn new skills.
9 Relies heavily on memorizing without understanding.
9 May be impulsive and prone to accidents.
9 Often uses an awkward pencil grip ( fist, thumb hooked over finger, etc. )
9 May have trouble learning to tell time.
9 May have poor fine motor co-ordination.
9 Appears very dumsy.

542 Indian Journal of Pediatrics, Volume 68--June, 2001

 Approach to Learning Disability

TABLE3. Middle School Characteristic

9 Reverse letter sequences - soiled for solid, brith for birth.

9 Slow to discern and to learn prefixes, suffixes, root words and other reading and spelling strategies.
9 Has difficulty spelling, spells same word differently on the same page.
9 Avoids reading aloud.
9 Has trouble with word problems in mathematics
9 Writes with illegible handwriting, with awkward, pencil-grip or, may avoid writing.
* Has slow or poor recall of facts
9 Has difficulty with comprehension
9 Has difficulty making friends
9 May not understand body language and facial expression of others.
9 Has trouble with non-literal language ( idioms, jokes, proverbs, slang )
9 Forgets to hand in homework or to bring in homework
9 Has difficulty with planning and time management.

TABLE4. High School Characteristics

9 Reads very slowly with many inaccuracies.

9 Continues to spell incorrectly, frequently spells the same word differently in a single piece of writing.
9 Procrastinates reading and writing tasks.
9 Avoids writing.
9 Has trouble summarizing and outlining.
9 Has trouble answering open-ended questions on tests, prefers objective type of questions.
9 Has poor memory skills
9 Works slowly.
9 Has poor grasp of abstract concepts.
9 Pays little attention to details or focuses too much on them.
9 Misreads information.
9 May not complete assignments; may complete them and not hand them in.
9 Has an inadequate vocabulary.
9 Has an inadequate store of knowledge from previous reading.
9 Has difficulty with planning and time management.

TABLE5. Characteristics in Adults with L.D. noted that soft signs do not provide useful diagnostic
criteria for indication of brain dysfunction in learning
9 Hide reading problems, many subterfuge. disabled children and their absence does not rule out
9 Spell poorly; rely on others. the possibility of L.D.
9 Avoid writing, may not be able to write.
* Often competent in oral language. Dexterity
9 Rely on memory; may have excellent memories.
9 May have good spacial talents. It has been found that the incidence of left handedness,
9 Often very good at "reading" people. ambidexiterity and crossed laterality is comparatively
9 Have difficulty with planning and organization. h i g h in children w i t h LD. The dexterity s h o u l d be
9 Have difficulty with time; often too early, late, or forget tested in hand, leg, eye and ear.
appointments. Rely on digital watches; cannot tell time. A n u m b e r of behavioural characteristics, academic
abilities, perceptual and developmental difference may
termed these signs as neuromaturational signs. These be present to a greater or lesser extent. The signs and
signs are minor, m a y often occur in n o r m a l y o u n g s y m p t o m s as per the age of the child or grade level
c h i l d r e n a n d are n o t n e c e s s a r i l y r e l a t e d to a n y may be useful for suspecting the diagnosis of learning
structural lesion in the brain. Therefore it should be disability. They are summarized in the Tables 1 to 5.

Indian Journal of Pediatrics, Volume 68--June, 2001 543

 Madhuri Kulkarni et al

LABORATORY TESTS 9 Basic Learning Skills.

9 Reading Comprehension
Research studies on learning disabled children have 9 Oral Expression
shown that some laboratory tests may be helpful in 9 Listening Comprehension
differentiating them from control group. 16 9 Written Expression
Electroencephalography studies have shown 9 Mathematical Calculation
abnormalities of rate and amplitude in approximately 9 Mathematical Reasoning
50% of learning disabled children. Focal or paroxysmal There are many educational tests available for this
abnormalities have been reported in a small proportion purpose. It not only helps in the diagnostic procedure
of patients. No specific EEG pattern has been found to but also indicates the specific abnormality in the
be diagnostic of learning disability. 17Therefore, process of learning. However, the test needs to be
routine EEG studies are suggested only for those critically selected for an individual child u n d e r
children with some evidence of specific seizure consideration. Any one or more of the following tests
disorder. may be used by the special educator to complete the
Imaging studies c o m p u t e d tomography and assessment.
magnetic resonance imaging scans of the brain have 1. Kauffman Test of Educational Assessment (K-TEA)
failed to show any consistent abnormalities involved in : Tests in reading, mathematics and spelling.
different forms of learning disabilities. Some studies 2. Woodcock - Johnson Psycho Educational Battery
have reported an association of symmetrical temporal (WJPB) : Cluster areas include reading, mathe-
lobes instead of asymmetry found in non-dyslexic matics and written language.
group. Neuronal migration defects and corpus 3. Stanford Diagnostic Reading Test (SDRT) and
callosum abnormalities have also been reported? 8
Stanford Diagnostic Mathematics Test (SDMT).
Vision and Hearing Test 4. Test of Written Language (TOWL). Test the Written
Expression.
A routine opthalmic and hearing test examination for 5. Wild Range Achievement Test-Revised (WRAT-R)
refractory error and hearing test should be undertaken Tests in reading, spelling and mathematics.
to detect deficits in the sensory system which lead to
6. Peabody Individual Achievement Test (PIAT)
learning difficulties in children.
The interpretation of test results should be
undertaken by an experienced diagnostician. Also, the
COGNITIVE ASSESSMENT
factors such as emotional factors, ADHD/ADD and
neurological disorders need to be taken into
Cognitive function is measured by a test of general
consideration while giving the report of educational
intelligence. The main purpose of this test is to assess
assessment.
the level of intellectual functioning which is taken as an
In a child with average intelligence an academic
indicator of child's potential for learning.
achievement two year below the actual grade
The most commonly used test for school age
placement is usually considered indicative of learning
children is the Weschlers Intelligence Scale for
disability.
Children (WISC-R) Indian adaptation. The WISC-R
consists of 12 subtests based on verbal and nonverbal
DIAGNOSIS
tasks. Each of the 12 subtests is scored separately as per
the age-norm. The six verbal subtests yield a verbal IQ
A multidisciplinary approach is essential for diagnosis
and the six nonverbal subtests yield a performance IQ.
of LD as there are very few objective diagnostic criteria
The verbal and performance scores are combined to
which are universally acceptable for learning
give a full scale/global IQ. A child with learning
disability. The following guidelines are useful in
disability may show a marked discrepancy between
making the diagnosis :
verbal and performance IQ scores. Also, a subtest
scatter may indicate the disability in a specific area.
1. Average or above average intellectual functioning
2. No evidence of peripheral sensory defects (visual
EDUCATIONAL ASSESSMENT
or hearing) which seriously interfere with
learning.
Educational assessment is an integral part of
3. Performance 2 years below grade level for the age
evaluation of a child with LD. 19 It involves the
on the basis of achievements test or achievement
administration of educational tests in the following
score below the 20th percentile.
areas of learning.2~

544 Indian Journal of Pediatrics, Volume 68--June, 2001

 Approach to Learning Disability

ASSOCIATED BEHAVIOURAL PROBLEMS AND child's strengths and weaknesses in such areas.
FAMILY DISTURBANCES Individualized supportive education by the remedial
teacher to learning disabled children in regular school
helps the students to catch up with education in
The u n d e r l y i n g basis of learning disability is a
regular class. It is important that the remedial teacher
neurophysiological defect in cognitive processing but
and the regular class-teacher work closely to plan the
the overall effect is a cascade of reactions that seriously
duration of remedial instruction and activities to teach
affects many other functions. Psychological problems
students in the regular and remedial class to improve
are commonly observed in children with learning
their performance.
disability. 21
These children tend to be easily influenced by
CONCLUSION
others. Some of them may get involved in antisocial
activity and risk taking behaviour. Serious emotional
Learning disability forms an important cause of failure
disturbances such as low self esteem, temper tantrums
in school in otherwise capable children. The learning
may be observed in children with LD. Many children
disabilities are often accompanied by problems of at-
lack self confidence. Some demonstrate difficulties in
tention and concentration, organization, mood and
a p p r o p r i a t e l y m a n a g i n g t h e m s e l v e s in social
emotions and feelings and social interaction. A
situations. multidisciplinary approach is essential for early recog-
All these issues place a great stress on the family.
nition of this disability. The appropriate curriculum
Parents of learning disabled children are often
adjustment, help the child attain his / her maximum
frustrated by problems they face in trying to get help
educational potential and become a productive and
for their child's problem. Many of them deny it. Most
contributing adult member of the society.
parents are deeply concerned about future educational
possibilities and economic limitations that their child
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