Specific

Learning
Disorder- II
Dr. Subhechhya Basnet
3rd year Resident
Department of Psychiatry
Specific learning disorder is a neurodevelopmental disorder with a
biological origin that is the basis for abnormalities at a cognitive level
that are associated with the behavioral signs of the disorder.
 Learning difficulties are considered “specific” for four
reasons.
• Not better explained by intellectual developmental disorders
• The learning difficulty cannot be attributed to more general
external factors
• The learning difficulty cannot be attributed to neurological or
motor disorders or to vision or hearing disorders, which are
often associated with problems learning academic skills but
are distinguishable by the presence of neurological signs.
• The learning difficulty may be restricted to one academic skill
or domain.
SLD in Written Expression
A condition diagnosed in childhood characterized by poor writing skills
that are significantly below the child's age, intelligence, and education,
and cause problems with the child's academic success or other
important areas of life.
Components of writing disorder include poor spelling, errors in
grammar and punctuation, and poor handwriting.

Also called dysgraphia, spelling disorder, and spelling dyslexia.

Spelling errors are among the most common difficulties for a child
with a writing disorder.

Spelling mistakes are most often phonetic errors;

• i.e. an erroneous spelling that sounds like the correct spelling.

• for e.g. fone for phone, or beleeve for believe.
 Etiology

Neuropsychological
Genetic factors Perinatal factors
factors
Neuropsychological Writing skills include both transcription and
factors composition (text generation)

Writers transform the words they want to use into

written(orthographic) symbols
Transcription It involves spelling and handwriting skills

It is based on phonological short-term memory

 The act of constructing written text

Composition (text Ideas are generated in memory and then

generation) transcribed onto the written page
It is based on verbal working memory

Difficulties in any one area 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 - poor spelling, as well as poor reading and
mathematics.

• Recent large-scale randomized trial –the relationship between

breastfeeding and children's cognitive development and academic
attainment at age 6 years, particularly in reading and writing.
 Signs and Symptoms of SLD in
Written Expression
One of the most common clinical features is noticeable and persistent
poor spelling for age
• often described as “atrocious spelling”
• often adds, omits, or substitutes vowels and consonants
• may spell phonetically but incorrectly, such as “pikchr” for
“picture”

Sentences are often very short or incomplete and contain grammatical

errors.
Written paragraphs are often short, poorly constructed, and organized
and their intended meaning is unclear.

Disordered and illegible handwriting

Fails to capitalize the first letter of the first word in a sentence.

“Procrastination”

• Common complaints from teachers (and parents)

• With great effort and reluctance, the youngster fails to start writing
and writes very little.
The person’s written work does not accurately reflect that individual’s
knowledge, creativity, or depth of understanding of an issue.

Also, essential written activities, such as note-taking, pose major

challenges.
 Assessment

Standardized test includes

• 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)
 Treatment
• A preventive approach of providing instruction in handwriting,
spelling, and composition is effective in improving subsequent spelling
and reading abilities.

• Explicit instruction in handwriting - directing attention to critical

features of letters and on-task demands.

• Other variables include a 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 three critical steps: Planning, writing the

first draft, and revision of the draft.

• P.O.W.E.R: Plan, Organize, Write, Edit, Revise

• C-SOOP: Capitalization, Sentence structure, Organization, Overall

format, Punctuation
SPECIFIC LEARNING
DISORDER WITH
IMPAIRMENT IN
MATHEMATICS
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.
 Etiology

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:

• a biologically based nonverbal capacity to estimate numerosity (non-
symbolic representation of numerical magnitude, such as arrays of
dots) - property of the visual system
• an acquired verbally based ability - through enculturation and formal
schooling
Neurological Factors
• The inferior parietal sulcus plays a dominant role in numerical
processing.
• fMRI - children use frontal regions during calculation, whereas adults
use 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.
• MRI studies - decreased gray matter in the left parietal lobe.
• Moreover, calculation ability was related to plasma taurine level in
the neonatal period since taurine is important in neural development.
Genetic Factors
• Family studies - 50 to 60 % of all siblings and parents of children with
mathematics disorder also have mathematics disorder.
• To date, no specific genes for mathematics disorder/dyscalculia
• Environmental Factors- Psychosocial adversity and schooling
• Affective factors - anxiety and motivation.
• Children from low-income households have a low level of number
sense— because of their poor experience.
Emotional Factors
• Math anxiety refers to increased physiological reactivity, negative
cognitions, avoidance behavior, and substandard performance when
presented with math stimuli.
• As math anxiety increases, working memory is compromised and
math achievement declines.
• Math anxiety is common, particularly in females.
 Signs and Symptoms of SLD in
Mathematics
Four groups of skills are poorly achieved
• Linguistic skills (understanding mathematical terms and converting
written problems into mathematical symbols),
• Perceptual skills (the ability to recognize and understand symbols
and order clusters of numbers),
• Mathematical skills (basic + , - , x, ÷), and
• Attentional skills (copying figures correctly and observing symbols
correctly).
• One common sign that persists across the lifespan is the sole reliance
on finger counting for simple addition and subtraction which is
inappropriate for age.

• Other common features include

• a poor sense of numbers in terms of their magnitude and relationship
• inaccurate counting and calculation;
• failure to attend to key mathematical symbols
• difficulty with identifying the previous or next item in a sequence
• difficulty understanding the concept and use of “zero” or decimal points
• “Gets lost” in the middle of multi-digit calculation and may switch
procedures or apply them incorrectly.

• Many struggle with understanding the “language” of mathematics,

especially in word problems.

• Older children, adolescents, and adults manifest difficulty

understanding and using money, telling the time, using calculators,
and remembering numerical pin codes.
• Math anxiety is another common feature that persists across the
lifespan.
• Often described as “a feeling of tension, apprehension, or fear that
interferes with math performance.”
• it may manifest as sweaty palms, a racing pulse, breaking out in a
cold sweat, or a choking feeling in the back of the throat when
required to perform mathematics in everyday life.
 Assessment
• Standardized measurement of intellectual function is necessary to
make this diagnosis.
• 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.
• Woodcock-Johnson Achievement Battery-III
• Test of Early Mathematical Abilities
• Teacher Academic Attainment Scale (TAAS)
• Math anxiety may be assessed using child self-reported math anxiety
scales
• Math Anxiety Questionnaire [11 items]
• Abbreviated Mathematics Anxiety Scale for Children [9 items])
 Treatment
• Psychoeducation about the disorder and its longer-term implications
is an essential first step.

• Mathematics difficulties are best remediated with early interventions

that lead to improved skills in basic computation.

• The presence of specific learning disorders in reading along with

mathematics difficulties can impede progress; however, children are
quite responsive to remediation in early grade school.
 • Reinforcement of acquired arithmetic skills,
Effective
educational • A concrete-to-abstract teaching sequence,
techniques for • Think-aloud procedures (i.e., Verbalization
children with while problem-solving),
• Creative strategies and mnemonics for
mathematics
sequential problem-solving,
disorders are those • Frequent monitoring of the student's
that incorporate progress, and teaching skills
Project MATH, a multimedia self-instructional training program

Several promising computer-based software programs (e.g., Number

Worlds; Number Race) have been developed.

Problem-solving skills in the social arena also help in mathematics.

Behavioral strategies (e.g., relaxation training, systematic

desensitization, visualization of successful math performance) are
effective for math anxiety.
 Associated Problems
• SLD is commonly, but not invariably, associated with a developmental
history of problems in speech and language, attention, and motor skills.
• Moreover, SLD commonly, but not invariably, co-occurs with other
neurodevelopmental (e.g., Communication Disorders, ADHD) and mental
health disorders (e.g., Anxiety and Mood Disorders).

• These associated problems are clinically important because the diagnosis of

SLD cannot be confirmed until the child has started school and been
exposed to formal academic instruction, but Communication Disorders in
particular are likely to be apparent and diagnosed earlier and so indicate a
risk for later SLD.
• Likewise, a developmental and family history of SLD may indicate a
risk for later anxiety and mood disorders in adolescence and
adulthood.
 1. Speech and Language Impairments
• One longitudinal study identified pervasive speech/language
disorders in kindergarten was found to have an estimated three- to
six-fold greater risk for SLD in young adulthood compared to
typically developing youngsters.
• Moreover, according to a recent population-based study, the
cumulative risk of SLD in written language by age 19 is about 64
percent in youngsters with speech/language impairments
compared to 18 percent in those without.
 2. Attention-Deficit/Hyperactivity Disorder
• Around 20 to 45 percent of children with ADHD also meet
diagnostic criteria for SLD.
• Inattention in the classroom is a robust predictor of concurrent and
subsequent poor academic outcomes.
• Youngsters with SLD who have coexisting inattention or ADHD
require multimodal intervention including intensive educational
intervention, since medication for ADHD will not address the SLD,
and intervention for SLD will be less effective if the inattention
remains unaddressed.
 3. Emotional Problems, Anxiety and Mood Disorders,
Suicide Risk
• Individuals with SLD are highly likely to manifest concurrent social,
emotional, and mental health problems.
• (About 70 percent) have higher rates of anxiety and depressive
symptoms compared to non-SLD peers.
• Episodes of severe anxiety or anxiety disorders are common across
the lifespan and accompany both the circumscribed and broader
expression of learning difficulties.

• SLD is associated with an increased risk for suicidal ideation and

suicide attempts in children, adolescents, and adults.
 Differential Diagnosis

Normal Variations In Academic

Attainment
Intellectual Disability Disorder
Learning Difficulties Due To Neurological Or Sensory Disorders

Neurocognitive disorders

ADHD
Psychotic disorders
 Take home message
The different types of specific learning disorders commonly co-occur with
one another and with other neurodevelopmental disorders or other mental
disorders or behavioral problems.

The comorbidities do not necessarily exclude the diagnosis of SLD and may
make testing and differential diagnosis more difficult, as they independently
interfere with the execution of activities of daily living, including learning.

Thus, clinical judgment is required to attribute such impairment to learning

difficulties.
 References
• Kaplan & Sadock’s Comprehensive Textbook of Psychiatry 10th Edition
• Kaplan & Sadock’s Synopsis of Psychiatry 11th Edition
• Rutter’s Child and Adolescent Psychiatry 6th Edition
• DSM-5 TR