Specific Learning Disabilities in India: Current Situation and the Path Ahead

Students with specific learning disabilities (SpLD) need timely remedial education and provisions to continue their education within the mainstream. The Government of India has enacted the Rights of Persons with Disabilities (RPwD) Act, 2016, and legitimized SpLD as a disability, nationally. This Act mandates screening of every school student for SpLD on completion of eight years of age, setting up of resource rooms for imparting remedial education in all schools, and provisions in examinations for all afflicted students. This Act authorizes that students with SpLD get benefit of reservations in higher education seats and government jobs. To ensure that this Act is implemented effectively, all stakeholders in the field of education and health will have to collaborate to set up sufficient number of assessment clinics, create sufficient number of special educators, and develop validated screening and assessment tools for diagnosing SpLD in all the regional languages of our country

A child with neurological deficits, electrolyte imbalance, and arrhythmia.

A child presented with an acute febrile illness associated with neurological symptoms. The differential diagnoses of such a presentation with effects of prolonged hospitalization is discussed.

Use of computerized tests to evaluate psychomotor performance in children with specific learning disabilities in comparison to normal children.

Background & objectives: Children with specific learning disabilities (SpLD) have an unexplained difficulty in acquiring basic academic skills resulting in a significant discrepancy between their academic potential and achievements. This study was undertaken to compare the performance on a battery of six psychomotor tests of children with SpLD and those without any learning disabilities (controls) using computerized tests. Methods: In this study, 25 children with SpLD and 25 controls (matched for age, socio-economic status and medium of instruction) were given three training sessions over one week. Then children were asked to perform on the six computerized psychomotor tests. Results were compared between the two groups. Results: children with SpLD fared significantly worse on finger tapping test, choice reaction test, digit picture substitution test and card sorting test compared to the controls (p<0.05). Interpretation & conclusions: Children with SpLD have impairment of psychomotor skills like attention, sensory-motor coordination and executive functioning. Further research is needed to evaluate if the remedial education plan results in improvement in psychomotor performance of children with SpLD on these selected tests.

Extracardiac Birth Defects in Children with Congenital Heart Defects.

Objective: To assess the proportion and pattern of extracardiac birth defects in children with congenital heart defects referred to a tertiary care institute. Methods: Cross-sectional observational study from January 2010 to June 2011. Results: Out of 560 children with congenital heart defects, 98 (17.5%) had extracardiac birth defects. Fifty-six had multiple congenital defects; 36 were syndromic cases and 6 had laterality defects. A total of 386 extracardiac birth defects (103 major and 283 minor) were documented, with craniofacial and skeletal birth defects being the commonest. Conclusion: Extracardiac birth defects are common in children with congenital heart defects.

Do fathers' attitudes support breastfeeding? a cross-sectional questionnaire-based study in Mumbai, India.

Context: The views of fathers have been shown to be important determinants of infant feeding decisions, but men's attitudes toward breastfeeding and formula feeding have rarely been explored. AIMS: To explore the relationship between maternal and paternal infant feeding attitudes and their impact on the duration of exclusive breastfeeding. Settings and Design: Prospective questionnaire-based cross-sectional study conducted in a tertiary care public hospital. Materials and Methods: From May 2009 to September 2010, a convenience sample of 238 parents of infants (>6 months to <1 year of age) were included. Each parent's attitude toward infant feeding was measured by the Iowa Infant Feeding Attitude Scale (IIFAS). Statistical Analysis Used: Pearson's correlation test, independent samples t-test, and one-way analysis of variance were carried out for statistical significance. Results: Only 83 (34.9%) mothers had exclusively breastfed their babies for 4-6 months. A mother's "total" infant feeding attitude score was significantly correlated with her husband's score ( r = 0.43, P < 0.01). The couples shared similar "individual" infant feeding attitudes to all but four of the 17 items. These 13 "individual" attitudes favorable toward breastfeeding were related to its optimal nutritional value, convenience of administration, ease of digestibility, unique role in mother-infant bonding, acceptability of breastfeeding in public places, and long-term health benefits to babies. Only maternal attitudes played an influential role in achieving an exclusive breastfeeding period of 4-6 months. Conclusions: Fathers' attitudes do support breastfeeding, but do not influence the time duration of exclusive breastfeeding.

Managing Specific Learning Disability in Schools in India.

Specific learning disability (dyslexia, dysgraphia, and dyscalculia) afflicts 5-15% of school-going children. Over the last decade; awareness about this invisible handicap has grown in India. However, much needs to be done to ensure that each afflicted child gets an opportunity to achieve his or her full academic potential in regular mainstream schools. In order to achieve this ideal scenario, all ‘regular’ classroom teachers should be sensitized to suspect, and trained to screen for this disability when the child is in primary school. School managements should become proactive to set up resource rooms and employ special educators to ensure that these children receive regular and affordable remedial education; and be diligent in ensuring that these children get the mandatory provisions both during school and board examinations. Once specific learning disability is recognized as a disability by the Government of India, these children with the backing of the Right to Education Act, would be able to benefit significantly.

Overlap Syndrome: Autoimmune Sclerosing Cholangitis.

A 9-year-old-girl presented with clinical features of autoimmune hepatitis and associated signs of cholestasis in the form of itching and elevated levels of serum alkaline phosphatase. There was histologic evidence of bile duct injury. Hence a clinical diagnosis of “overlap syndrome” of autoimmune hepatitis with primary sclerosing cholangitis was considered.

Impact of attention-deficit/hyperactivity disorder on health-related quality-of-life of specific learning disability children.

Objective. To evaluate the impact of co-occurring attention-deficit/hyperactivity disorder (ADHD) on the health-related quality of life (HRQOL) of children with newly diagnosed specific learning disability (SpLD). Methods. From September 2005 to March 2006, 150 parents (either mother or father) of children consecutively diagnosed as having SpLD were enrolled. The Child Health Questionnaire-Parent Form 50® (CHQ-PF50®) was used to measure parent-reported HRQOL. CHQ-PF50® mean domain and summary scores computed for “SpLD/ADHD” and “SpLD only” children groups were compared using Independent Samples t-test. Results. HRQOL of “SpLD/ADHD” children was significantly poorer in four domains: emotional impact on parents (mean difference: -11.0 ; 95% CI: -18.75 – -3.25; P = 0.006), general behavior (-9.61; 95% CI: -15.44 – -3.78; P = 0.002), time impact on parents (-9.51; 95% CI: -18.42 – -0.60; P = 0.038), and, self esteem (-7.62; 95% CI: -13.98 – -1.26; P = 0.020); and in overall psychosocial functioning (-5.34; 95% CI: -8.49 – -2.19; P = 0.001). Conclusion. Co-occurring ADHD adversely impacts the HRQOL of children with newly diagnosed SpLD especially in domains related to their psychosocial functioning.

Recollections of learning-disabled adolescents of their schooling experiences : A qualitative study.

Background: Little is known about the actual impact of the schooling experience on adolescents with specific learning disability (SpLD). Aims: To analyze the recollections of adolescents with SpLD who were undergoing education in regular mainstream schools. Settings And Design: Prospective interview-based study conducted in our clinic. Materials And Methods: Adolescents' responses to a semi-structured interview were audio-taped, transcribed verbatim and interpreted by content analysis. The number of participants was determined by 'saturation sampling,' resulting in a total of 30 adolescents. Results: Twelve (40%) adolescents had 'overall' neutral recollections, 9 (30%) had 'overall' positive recollections and 9 (30%) had 'overall' negative recollections about having SpLD during their schooling. Fourteen (46.7%) adolescents stated 'getting provisions' as good features, whereas 7 (23.3%) stated 'feeling different from classmates' and 6 (20%) stated 'being teased by classmates about their disability' as bad features of having SpLD. Nineteen (63.3%) adolescents remembered classroom teachers being supportive, while 7 (23.3%) remembered being insulted by them. Of the 21 adolescents who had undergone remedial education, only 10 (47.6%) acknowledged that it had benefited them. Twenty-one (70%) adolescents stated that availing provisions helped in getting better marks in examinations. Ten (33.3%) adolescents had negative recollections about their parents' behavior in relation to their disability. Twenty (66.7%) adolescents wanted changes in their school to help students with SpLD. Conclusion: Improving the knowledge of classroom teachers, classmates and family members about SpLD and about the rationale of provisions will help reduce the unpleasant experiences students with SpLD undergo during their schooling years.

Leptospirosis in children: A review for family physicians.

Leptospirosis is an important cause of acute febrile illness in the monsoon season in India. It is a zoonotic disease that is spread primarily by rodents. There exist two clinical types: anicteric and icteric leptospirosis. Both have an initial septicemic phase followed by an immune phase. The clinical manifestations vary and the disease manifestations may range from a nonspecific febrile illness to one with severe multiorgan failure. Weil's disease is the severe form of the infection; which occurs in less than 10% of the patients and is associated with high mortality. The methods available for diagnosis and treatment of leptospirosis are discussed in this review. Crystalline penicillin is the drug of choice for treatment of leptospirosis in children. Avoidance of contact with flood waters and rodent control are vital for prevention of the disease. We also discuss the differences between childhood leptospirosis and adult disease. We used two methods to garner the information presented in this article: i) we searched the PubMed database (http://www.ncbi.nlm.nih.gov/pubmed/) using the keywords 'leptospirosis' and 'children,' with special emphasis given to articles from the Indian literature; and ii) we reviewed the chapters on leptospirosis in the standard textbooks of pediatric and infectious diseases.

Bone metabolism alteration on antiepileptic drug therapy.

OBJECTIVE: To investigate whether serum total alkaline phosphatase (ALP), bone-specific ALP (bone ALP), calcium, phosphorus, 25-hydroxyvitamin D (25-OHvit D) concentrations are altered early in the course of treatment with carbamazepine or valproic acid monotherapy in ambulatory children with adequate sun exposure; and to determine the effectiveness of simultaneous supplementation with calcium and 25-OHvit D at recommended dietary allowance doses on these biochemical parameters. METHODS: For each drug, children were divided into two groups (Group A: without supplementation; and Group B: with supplementation) and serum biochemical parameters estimated at 0, 30, 60, and 90 days of starting treatment. Statistical analysis: Serial changes in serum biochemical parameters (mean +/- SD) were compared within each of the four groups using student's paired t test. Also for each drug, serum biochemical parameters were compared between Groups A and B at 0, 30, 60, and 90 days of starting treatment using student's unpaired t test. RESULTS: For both drugs, in Group A, serum total ALP levels were significantly increased above the normal range (P<0.0001) by 90 days of starting treatment; however, serum bone ALP level was significantly increased (P=0.002) only in children on valproic acid. For both drugs when serum biochemical parameters were compared between Groups A and B, supplementation resulted in a significant decrease in serum total ALP (P<0.0001) and bone ALP levels (P<0.001), and a significant increase in serum calcium (P<0.0001) and 25-OHvit D levels (P<0.0001) by 90 days of starting treatment. CONCLUSION: Serum biochemical changes which indicate predisposition to development of rickets or osteomalacia appear within 90 days of starting carbamazepine or valproic acid monotherapy. However simultaneous supplementation with oral calcium and 25-OHvit D is effective in preventing the development of these adverse biochemical changes.

Posterior reversible encephalopathy syndrome revealing Takayasu's arteritis.

Posterior reversible encephalopathy syndrome is a rare neuroradiologic condition associated with headache, seizures, altered sensorium, visual disturbances, and characteristic lesions on neuroimaging predominantly affecting the posterior regions of the brain. We report a 10-years-8-months-old girl who presented with headache, multiple seizures, and altered sensorium. Her blood pressure was 130/100 mmHg and left brachial pulse was not palpable. CT scan brain showed typical non-enhancing hypodensities in bilateral parieto-occiptal lobes. Prompt treatment of the hypertension led to rapid reversal of neurological symptoms. CT aortogram revealed aortoarteritis with bilateral renal artery stenosis.

Impact of an educational program on parental knowledge of cerebral palsy.

OBJECTIVES: To investigate parental knowledge of cerebral palsy, and to evaluate the impact of an educational intervention on it. METHODS: From May 2003 to April 2004, 26 parents of newly diagnosed children with cerebral palsy were interviewed. After the interview, each parent was administered a structured educational program and re-interviewed after three months. The pre and post intervention responses were compared using Chi-square test. RESULTS: After the intervention, there was a significant improvement in parental knowledge: (i) of the cause of the disorder (5/26 vs 20/26, P = 0.0001), (ii) that it is non-progressive (16/26 vs 24/26, P = 0.021), (iii) that it is not curable (10/26 vs 23/26, P = 0.0005), (iv) that it is treatable (12/26 vs 24/26, P=0.0009), (v) of the frequency and duration of therapy necessary to improve functional abilities (7/26 vs 17/26, P = 0.005), and, (vi) of the importance of following up regularly with a pediatrician (17/26 vs 26/26, P = 0.003). However, there was no significant improvement in parental knowledge: (i) of the meaning of the term 'cerebral palsy' (0/26 vs 5/26, P = 0.060), (ii) that 'early intervention therapy' given by a team of therapists is its recommended therapy (18/26 v 23/26, P = 0.174), (iii) of the meaning of the term 'early intervention therapy' (12/26 vs 17/26, P = 0.163), and (iv) that it is preventable with good medical care (8/26 vs 10/26, P = 0.560). CONCLUSION: Parental knowledge of cerebral palsy is inadequate. A single-session educational program can significantly improve parental knowledge about many 'core basic issues' regarding cerebral palsy.

Clinical and psychoeducational profile of children with borderline intellectual functioning.

OBJECTIVE: To document the clinical profile and academic history of children with borderline intellectual functioning ("slow learners"); and to assess parental knowledge and attitudes regarding this condition. METHODS: From November 2004 to April 2005, 55 children (35 boys, 20 girls) were diagnosed as slow learners based on current level of academic functioning and global IQ scores (71-84) done by the WISC test. Detailed clinical and academic history; and physical and neurological examination findings were noted. The parents were counseled about the diagnosis and the option of special education. RESULTS: The mean age of slow learners was 11.9 years (+/-SD 2.3, range 8-17). Eighteen (32.7%) children had a significant perinatal history, 15 (27.3%) had delayed walking, 17 (30.9%) had delayed talking, 17 (30.9%) had microcephaly, 34 (61.8%) had presence of soft neurologic signs, and 10 (18.2%) were on complementary and alternative medication therapy. There were no differentiating features between the two gender groups. Their chief academic problems were difficulty in writing (92.7%), overall poor performance in all subjects (89.1%), and difficulty in mathematics (76.4%). Forty-six (83.6%) children had failed in examinations, 34 (61.8%) had experienced grade retention, and 32 (58.2%) had behavior problems. Most parents (83.3%) were reluctant to consider the option of special education. CONCLUSION: Slow learners struggle to cope up with the academic demands of the regular classroom. They need to be identified at an early age and their parents counseled to understand their academic abilities.

Clinical and psychoeducational profile of children with specific learning disability and co-occurring attention-deficit hyperactivity disorder.

BACKGROUND: Almost 10% of school-going children have specific learning disability (SpLD) in the form of dyslexia, dysgraphia and/or dyscalculia. Attention-deficit hyperactivity disorder (ADHD) occurs as a comorbidity in about 20% of these children. AIMS: To document the clinical profile and academic history of children with SpLD and co-occurring ADHD. SETTINGS AND DESIGN: Prospective observational study conducted in our clinic. MATERIALS AND METHODS: From August to November 2004, 50 consecutively diagnosed children (34 boys, 16 girls) were included in the study. SpLD was diagnosed on the basis of psychoeducational testing. Diagnosis of ADHD was made by DSM-IV-revised criteria. Detailed clinical and academic history and physical and neurological examination findings were noted. STATISTICAL ANALYSIS: Chi-square test or unpaired student's t-test was applied wherever applicable. RESULTS: The mean age of children was 11.4 years (+/-SD 2.5, range 7-17.1). Fifteen (30%) children had a significant perinatal history, 12 (24%) had delayed walking, 11 (22%) had delayed talking, 5 (10%) had microcephaly, 27 (54%) displayed soft neurological signs and 10 (20%) had primary nocturnal enuresis. There were no differentiating features between the two gender groups. Their academic problems were difficulties in writing (96%), inattentiveness (96%), difficulties in mathematics (74%), hyperactivity (68%) and difficulties in reading (60%). All children had poor school performance, 15 (30%) had already experienced class retention and 20 (40%) had developed aggressive or withdrawn behavior. CONCLUSION: Children with SpLD and co-occurring ADHD need to be identified at an early age to prevent poor school performance and behavioral problems.