Specific Learning Disorder: Dr.R.G.Enoch MD Psychiatry II Yr GMKMCH, Salem
Specific Learning Disorder: Dr.R.G.Enoch MD Psychiatry II Yr GMKMCH, Salem
Specific Learning Disorder: Dr.R.G.Enoch MD Psychiatry II Yr GMKMCH, Salem
DISORDER
DR.R.G.ENOCH
MD Psychiatry II Yr
GMKMCH, Salem
• Introduction
• History
• DSM & ICD
• Epidemiology
• Specific learning disorder with impairment in reading
• Specific learning disorder with impairment in mathematics
• Specific learning disorder with impairment in written expression
• Comorbidities
• Complications
• Conclusion
Introduction
• 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.
Definition
• In contrast, in RD demonstrate
• underactivation in both posterior systems (left temporoparietal, left occipitotemporal) and
• increased activation in the left inferior frontal gyrus, right temporal and tempoparietal regions.
• So they rely more heavily on right-sided posterior brain systems to read via memorization rather than
by sound–symbol linkages and so continue to struggle to read unfamiliar words.
Imaging
• MRI studies - planum temporale in the left brain shows less asymetry
than the right brain.
• PET studies - left temporal blood flow patterns during language tasks
differ between children with and without SLD.
• Cell analysis studies - the visual magnocellular system (which normally
contains large cells) contains more disorganized and smaller cell bodies
than expected.
Genetic Factors
• RD is highly familial and heritable.
• Upto 50 % of children of parents with RD and 50 % of siblings of a child with RD may
have the disorder.
• Twin studies - high concordance rates for RD. Genetic factors account for 69 to 87 %
and 13 to 30 % is due to environmental factors.
• Molecular genetic studies of RD have reported several susceptibility loci on
chromosomes 1p, 2p, 3p, 6p, 11p, 15q, 18p, and Xq27.3.
• Chromosome 1p – common susceptibility locus for both reading disorder and
inattention dimension of ADHD
Cognitive Factors
•Brain imaging studies have revealed anatomical, metabolic, and activation differences in the
cerebellum of individuals with RD.
4. Visual/Magnocellular Theory
•most ubiquitous and influential theories of dyslexia
•emphasizes a visual contribution to reading problems
•Proposed visual problems include unstable binocular fixations, poor visual tracking, abnormalities in
perception of visual motion and poor contrast sensitivity.
•mechanism - disruption of the magnocellular pathway
•deficits anywhere along the magnocellular pathway can affect the spatiotemporal gating functions that
are essential for reading a text by spotlighting the individual letters of a text in a sequential fashion.
Signs of Reading Disorder
Kindergarten
Lack of interest in playing games with language sounds (e.g., repetition, rhyming)
Trouble learning nursery rhymes
Failure to recognize letters in their own name
Trouble remembering names of letters, numbers, or days of the week
Unable to recognize phonemes (e.g., does not know which of the set of words “dog,” “man,” “car” starts
with same sound as “cat”)
Primary Grades (Grades 1–3)
Receives reports of “not doing well in school”
Unable to read one-syllable words, such as “mat” or “top”
problems in connecting sounds and letters (e.g., “big” for “got”)
Difficulty in sequencing numbers and letters
Middle Grades (Grades 4–6)
Mispronounces or skips parts of long words (e.g., says “conible” for “convertible” and “aminal” for “animal”)
Confuses words that sound alike (e.g., “tornado” for “volcano”)
Trouble remembering dates, names, telephone numbers
Gets the first part of word correct, then guesses wildly (e.g., reads “clover” as “clock”)
Poor comprehension
Trouble completing homework or tests on time
Terrible spelling
Fear of (refuses) to read aloud, avoids reading
High School, College, Work
Slow, effortful reading of single words and connected text
Trouble pronouncing multisyllable words
Frequent need to reread material to understand
Avoids activities that demand reading (reading for pleasure, reading instructions)
Assessment
LEVEL -1
• YOUNGER STUDENTS (5-7 YEARS)
Level II
• OLDER STUDENTS (8 to 12 years)
1. ATTENTION
1. Simple Colour Cancellation test.
2. Double Colour Cancellation test.
2. VISUAL DISCRIMINATION
3. VISUAL MEMORY
4. AUDITORY DISCRIMINATION
5. AUDITORY MEMORY
7. VISUAL-MOTOR SKILLS
8. WRITING SKILLS
a. Capital letters
b. Small letters
c. Write the letter that comes before and after
9. NUMBERS
a. Write the numbers up to 20
• Psychological Factors
• Neurological Factors
• Genetic Factors
• Environmental Factors
• Emotional Factors
Psychological Factors
Core neuropsychological factor - impairment in number sense.
The term number sense is used to refer to two distinct constructs:
Environmental Factors
• Psychosocial adversity and schooling, and
• Affective factors - anxiety and motivation.
• Children from low-income households have a low level of number sense—
because of their poor experience.
Emotional Factors
• Neuropsychological Factors
• Genetic Factors
• Perinatal Factors
Neuropsychological Factors
• Writing skills include both transcription and composition (text generation).
• Transcription
• writers transform the words they want to use into written (orthographic) symbols;
• Ideas are generated in memory and then transcribed onto the written page.
• Difficulties in any one area (e.g., transcription, listening or reading comprehension, working memory) can delay skill
development and efficient functioning in another.
Genetic Factors
• Family studies - youth with impaired written expression have first-degree relatives with
similar difficulties.
• Twin studies - the heritability of spelling deficits to be higher than the heritability of
reading deficits.
• Molecular genetic studies –
• spelling disability - chromosome 15
• orthographic skills - chromosome 6.
• Four candidate genes (DYX1C1 on 15q, KIAA0319 and DCDC2 on 6p, and ROBO1 on 3q).
Perinatal Factors
• Extreme prematurity (i.e., <28 weeks' gestation or birth weight of <1,000
g) - poor spelling, as well as with poor reading and mathematics.
• recent large-scale randomized trial - relationship between breastfeeding
and children's cognitive development and academic attainment at age 6
years, particularly in reading and writing.
Clinical Features
Avoidance of written work
Only a few words or sentences in the same time when other students produce several
paragraphs
Disordered and illegible handwriting (e.g. admixture of printing and cursive writing; inappropriate
admixture of upper- and lower-case letters, inverted letters)
essential written activities such as notes taking is difficult – as it involves simultaneous listening,
comprehending, retaining information, process new information, and summarizing the important
points rapidly into a legible and useful format for subsequent review.
Common spelling problems
Confusion of similar letters or sounds (e.g., “jumpt” for “jumped”; “caterpault” for
“catapult”)
Frequent use of nonpermissible letter strings (e.g., “egszakt” for “exact”; “freeeqwnt”
for “frequent”)
Same word spelled in different ways within one piece of written work
Standardized Tests for Assessing Written Expression
• Explicit instruction in handwriting - directing attention to critical features of letters and on-task
demands
• Other variables include sequence in which letters are introduced, paper position, and pencil grip
• Spelling can be improved by systematic spelling instruction that focuses on letter patterns
(orthography) and opportunities to practice writing.
• Writing involves teaching of three critical steps: Planning, writing the first draft, and revision of
the draft.
• The inclusion of mnemonics (e.g., P.O.W.E.R: Plan, Organize, Write, Edit, Revise; C-SOOP:
Capitalization, Sentence structure, Organization, Overall format, Punctuation) provides an
effective reminder to the sequence of processes and steps being taught.
COMORBIDITY
• Reading and mathematics disorder frequently occur comorbidly with language disorder. Children with
language disorder have
• poor word knowledge,
• impairments in the ability to put words together to produce clear explanations and
• There are also high rates of comorbidity between reading impairment and mathematics impairment -
up to 60 percent.
• communication disorders (primarily with mixed receptive-expressive language disorder), as well as with
developmental coordination disorder.
• 25 % of children with SLD may have comorbid ADHD. Same genetic factors contribute to
both reading impairment and attentional syndromes. The major link appears to be
between the inattention dimension of ADHD and RD.
• high rates of depressive moods and feelings of lack of control and poor self-esteem
• Oppositional Defiant Disorder, Conduct Disorders especially in adolescents.
• Genetic deficits (e.g., velocardiofacial syndrome, fragile X syndrome, Down syndrome,
Williams' syndrome, Gerstmann's syndrome),
Differential Diagnosis
• A diagnosis of SLD is not usually made before the child is about 6 or 7 years old because evidence
of failure to learn to read is required.
Intellectual disability syndromes in which most skills, are below the achievement expected for a
child's chronological age. Intellectual testing helps to differentiate.
Inadequate schooling - can be detected by comparing a given child's achievement with classmates
on reading performance on standardized reading tests.
Hearing and visual impairments should be ruled out with screening tests.
Impaired motor coordination, arising from developmental coordination disorder or neurological
damage, may produce illegible handwriting, but in the absence of additional impairments in
spelling and expression of thought in writing, a disorder of written expression is ruled out.
COMPLICATIONS
• often find it difficult to keep up with their peers in certain academic subjects, whereas they may
excel in others.
• often leading to demoralization, low self-esteem, chronic frustration, and compromised peer
relationships.
• increased risk of comorbid disorders, including attention-deficit/hyperactivity disorder (ADHD),
communication disorders, conduct disorders, and depressive disorders.
• are at least 1.5 times more likely to drop out of school, approximating rates of 40 percent.
• Adults with are at increased risk for difficulties in employment and social adjustment.
• NGO found in 1992
• remedial help and support to children
• spreading awareness
• Hosts learning centres in school in tamil nadu
• Conduct training for teachers
Summary
• DSM-5 combines the DSM-IV diagnoses of reading disorder, mathematics disorder, and disorder of written
expression and learning disorder NOS into a single diagnosis: Specific learning disorder.
• Dyslexia is characterized by difficulties with inaccurate word recognition and poor spelling and decoding
abilities resulting from a deficit in the phonological component of language.
• Mathematics disorder refer to impairment in the development of arithmetic skills, including computational
procedures used to solve arithmetic problems and the retrieval of basic arithmetic facts from long-term
memory.
• Disorder of written expression Is characterized by poor writing skills like poor spelling, errors in grammar
and punctuation, and poor handwriting
• SLD could cause complications if not remedied earlier.
Conclusion
• Intense and focused instruction may in fact alter the brain activation profiles observed
in children with SLD.
• Thus, clinicians need to be aware that recommendations for placement in special
education may not alone be sufficient to improve reading or arithmetic skills.
• Rather, they need to advocate for intense and focused instruction in each of the
affected academic domains.
• Also, given the importance of literacy and numeracy skills in health, clinicians are
advised to screen for health literacy and numeracy in all children.
References
• Kaplan and Sadocks Comprehensive textbook of Psychiatry – 10th edition
• Kaplan and Sadocks Synopsis of Psychiatry – 11th edition
• Postgraduate Textbook of Psychiatry – Ahuja 3rd edition
• Rutter’s child and adolescent psyhiatry – 6th edition
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