Indian Academy of Pediatrics (IAP) eM Op 2 % rarro™ we a oe STANDARD TREATMENT GUIDELINES 2022 a ‘\ Specific Learning - Disorders Lead Author Dr Nandita D Souza Co-Authors Dr ASomasundaram Dr Swati Vinchurkar Under the Auspices of the IAP Action Plan 2022 Remesh Kumar R IAP President 2022 Upendra Kinjawadekar Piyush Gupta IAP President-Elect 2022 In? President 2021 Vineet Saxena WAP HSG 2022-2023AN Ac, wre wo 3 & ° 9 no Say © Indian Academy of Pediatrics IAP Standard Treatment Guidelines Committee Chairperson Remesh Kumar R JAP Coordinator Vineet Saxena National Coordinators ‘SS Kamath, Vinod H Ratageri Member Secretaries Krishna Mohan R, Vishnu Mohan PT Members Santanu Deb, Surender Singh Bisht, Prashant Kariya, Narmada Ashok, Pawan KalyanSpecific Learning Introduction Disorders Specific learning disorders (SLDs) are neurodevelopmental conditions, typically seen in school \ aged children, characterized by impairment in at least one of three major areas: reading, } written expression, and/or math. They occur in 1.6-15% of Indian children and have profound ] academic and psychosocial consequences. yi Learning struggles should be identified and corrected early. Children must Jearn to read by standard 2, so they can read to learn from standard 3 onward. Do not wait for children to fall \ Scientific evidence shows that grade retention does not improve academic performance. jyueyoduySpecific Learning Disorders Early Signs of Specific Learning Disorder BRH8THRARAA © Peer rejection, bullying, and difficulty with friendships a Speaks later than most children, articulation problems, poor vocabulary Difficulty rhyming words Very restless, fidgety, and easily distracted Difficulty following directions or routines Poor fine motor skills (using scissors, buttoning, drawing, and writing) and clumsiness gag a4 \ Trouble learning numbers, alphabet, days of the week, colots, and shapes ]% Struggles to learn the connection between letters and sounds. Makes frequent reading and spelling errors including letter reversals (b/d), inversions (m/w) and substitutions (house/home), jumbled letter sequences (soiled/solid, left/felt), and errors with aksharas and maatras Poor reading comprehension Trouble with open-ended questions on tests and poor written expression ‘Weak grasp of conceptual information Difficulties across all languages taught in school Transposes number sequences (35/53) and confuses arithmetic signs (+/—) Slow to remember number facts, trouble with word problems in Maths Maladaptive pencil grip (too light or too heavy pencil strokes) and avoids writing Difficulty remembering sequences (multiplication tables and stories) Relies heavily on memorization to overcome poor understanding Impulsive, distractible, and disorganized (incomplete assignments and books untidy) School avoidance and absenteeism, leading to dropout. Fa Z § ri Hl s ‘| Fy | H csSpecific Learning Disorders Assessment © Attention deficit hyperactivity disorder (ADHD) F Anxiety/depression Autism spectrum disorder [ Developmental coordination disorder. SUOI}IPUOD PIqiowoD History—including nature of learning challenges, chronology and academic performance, any previous help received, child's strengths and interests, birth details, development (especially language and motor skills) and behavior, family and social history, home language and medium of instruction, medical history including allergies, and sleep and chronic diseases. % Clinical evaluation—physical examination including anthropometry, neurocutaneous markers, dysmorphology, neurodevelopmental assessment, and learning screening (ask child to read a passage from simple age appropriate story book, write one to three sentences about themselves, solve class appropriate Maths sums, and spelling words from textbook). Hearing and vision must be assessed. Reports from school—check child's notebooks, examination results, perusal of examination answer sheets, and teachers’ reports &_Neuropsychological assessment—evaluation of cognitive level and academic abilities, using standardized psychometric tests, mental health evaluation, other multidisciplinary assessments by occupational therapist, speech and language pathologist, etc. Pane eats ‘Name of psychometric test ‘Age group Wechsler intelligence Scale for Children V (WISC V) 6-16 years Malin’s Intelligence Scale for Indian Children (MISIC) 6-16 years Binet Kamat Test (cognitive level 3-22 years NIMHANS index for specific learning disorder (SLD) levels 1 and 2 (English/Hindi/ 5-12 years. Kannada) Curriculum-based tests (designed by teacher/psychologist using textbooks and School age. following specified guidelines) Grade Level Assessment Device (GLAD) for standard 1-4 (English/Hindi) 6-10 yearsSpecific Learning Disorders As per the Diagnostic and Statistical Manual of Mental Disorders, Fifth Edition (DSM-S) criteria (2013), the following four criteria must be met for a diagnosis of SLD. 1. Difficulties in at least one of the following areas for at least 6 months despite targeted help: i. Difficulty reading (e.g, inaccurate, slow, and only with much effort) ii, Difficulty understanding the meaning of what is read iii, Difficulty with spelling iv. Difficulty with written expression (e.g, problems with grammar, punctuation, or organization) v. Difficulty understanding number concepts, number facts, or calculation vi, Difficulty with mathematical reasoning (e.g., applying math concepts or solving math problems). 2. Academic skills that are substantially below what is expected for the child's age and cause problems in school, work, or everyday activities. 3. Difficulties start during school age. 4. Leatning difficulties are not due to other conditions, such as intellectual disability, vision or hearing problems, aneurological condition (e.g,, head injury), socioeconomic disadvantage, poor teaching, or unfamiliarity with the medium of instruction. Diagnosis Intervention can be categorized into Remediation: A structured approach to teach critical literacy and numeracy skills such as phonological awareness, decoding, number place value, etc, Accommodations: Changes in presentation of materials e.g, using videos and audiobooks), assessments (e.g, use of scribe, oral exams, and objective type papers), settings (e.g, sit close to teacher and work in smaller groups), organization aspects (e.g, frequent breaks, shorter tasks, and extra time). © Modifications: Changes in what a child is taught or what she/he is expected to learn, e.g, lower level of math, dropping additional languages, simplified curriculum, etc =" a) ee] ee) es history (learning screen) son from school ‘testing Confimation of diagnosis ‘and cotiiation ve] [me | Remediation {literacy and numeracy skis) uoUansezu]Specific Learning Disorders / a: Specific learning disorder is one of the benchmark disabilities under the Rights of / Persons With Disability Act, 2016 which ensures right to free education till 18 years, 5% Role of Pediatricians reservation for admission to Government institutes for higher education, and 1% reservation in Government jobs. @ The Central Board for Secondary Education (CBSE), Indian Certificate of Secondary Education (ICSE), and various State Boards (Goa, Gujarat, Kerala, Karnataka, Maharashtra, and Tamil Nadu) offer accommodations, modifications, and examination concessions. © Early detection and referral for assessment of poor scholastic performance Liaison between the child, family, multidisciplinary team, school staff, special educator/ remedial teacher, and provision of ongoing monitoring Interpretation and explanation of the neuropsychology and multidisciplinary test reports to the child and family © Advocacy—guidance about cettification, statutory provision of concessions, and access to educational services Encourage parents to practice self-care, foster the child's strengths, understand challenges from the perspective of neurologic functioning, support the child's learning needs, and promote self-esteem. Ade20apy pue SUOISIAO’dSpecific Learning Disorders Further Reading American Psychiatric Association. Diagnostic and Statistical Manual of Mental Disorders (DSM-5*), Sth edition, Washington, DC: American Psychiatric Association; 2013, Ministry of Social Justice and Empowerment. The Rights of Persons With Disability (RPWD) Act 2016. Government of India: Ministry of Social Justice and Empowerment; 2016. [National Consultation Meeting for developing Indian Academy of Pediatrics (IAP), Guidelines ‘on Neuro-developmental Disorders under the aegis of IAP Childhood Disability Group and the Committee on Child Development and Neurodevelopmental Disorders, Nait MKC, Prasad C, Unni J, Bhattacharya A, et al. Consensus Statement of the Indian Academy of Pediatrics on Evaluation and ‘Management of Learning Disability. Indian Pediatr. 2017;54(7):574-80. National Education Policy 2020. New Delhi: Union Cabinet of India 2020. NCLD. National Centre for Learning Disabilities. (online) Available from: httpsv/wwwuncld.org. [Last accessed August, 2022] [Shah HR, Sagar JKV, Somaiya MP, Nagpal JK. Clinical practice guidelines on assessment and management of specific learning disorders. Indian J Psychiatry. 2019,61 (Suppl 2):211-25.