INTRODUCTION
Academic skills form the foundation upon which a student’s performance at school is assessed. For some children, mastering the basic academic skills create inordinate difficulties. Children with learning disorders exhibit academic difficulties out of proportion to their intellectual capacity. As per the international classification of diseases (ICD 10) by the world Health Organization, learning disorders are termed as specific developmental disorders of scholastic skills (SDDSS).
“My son is not interested in studies. Even if I teach him every lesson today, he forgets it tomorrow. He does not copy the school notes . He is getting very low marks in exams.” This was the problem for which a seventh standard student was brought by his mother to adolescent clinic. On evaluation, this boy was found to have learning disorder. His intelligence was above average but his reading, writing and mathematical skills were very low. He was given remedial education and within six months his academic skills improved. His interest in studies also improved remarkably, after motivational counseling.
PREVALENCE
In general, learning disorders occur in approximately 10% of school going children. Prevalence as low as 3% to as high as 20.6% have been reported from various parts of the country.
ETIOLOGY
The genetic hypothesis is based on twin studies and family studies. Twin studies have reported high concordance rates of about 100 percent for monozygotic twins and 35 percent for dizygotic twins.
Several studies have found evidence for linkage of phonological awareness and reading skills to particular regions of chromosome 6(phonological awareness) and chromosome 15(word reading)
Genetic predisposition on one hand and psychosocial factors as well as special learning conditions on the other, interact with one another. Genetic, developmental and environmental attributes may contribute to the deficits in learning ability. Children with extremely low birth weight and prematurity are at higher risk for developing learning disorders.
SUB TYPES
Specific reading disorder
The main feature of this disorder is the specific and significant impairment in the development of reading skills. Reading performance should be significantly below the level expected on the basis of age, general intelligence and school placement. There may also be deficits in reading comprehension.
Specific spelling disorder
The spelling performance of the child should be significantly below the expected level regarding age, general intelligence and school placement. There is specific and significant impairment in the development of spelling skills. Ability to spell orally and to write out words correctly are both affected. It may be associated with grammatical errors, punctuation errors, poor paragraph organization and poor handwriting.
Specific disorder of arithmetical skills
The arithmetical performance should be significantly below what is expected on the basis of age, general intelligence and school placement. The arithmetical difficulties may include failure to understand the basic concepts of arithmetical operations, lack of understanding of mathematical terms or signs, failure to recognize numerical symbol, poor spatial organization of arithmetical calculations, difficulty in properly aligning number and inability to learn mathematical tables satisfactorily.
Mixed disorders of scholastic skills
The reading skills, spelling skills and arithmetical skills are significantly impaired in these students. It includes disorders that meet the criteria of ‘specific disorder of arithmetical skills’ and either ‘specific reading disorder’ or ‘specific spelling disorder’.
ASSOCIATED PROBLEMS
Scholastic backwardness causes stress for many students. Parents and teachers are also worried regarding the deterioration in scholastic performance of children. In a society where personal worth and appreciation are gained by measures of academic achievement, learning difficulty becomes a source of significant stress for some students, leading to low self esteem, anxiety and behavioral problems.
Adolescents with learning disorders are at higher risk for social skills difficulties , expressive and receptive language disorders, attentional problems, anxiety, behavior disorders and depressive disorders. Up to 25% of students with reading disorder are found to have attention deficit hyperactivity disorder.
ADOLESCENTS WITH ACADEMIC STRESS
14 year old girl was brought to adolescent clinic with history of severe low back ache of three years duration. Detailed clinical examination did not reveal any organic pathology. Hematological and radiological investigation were normal. MRI –lumbosacral spine was within normal limits. Bone scan was also normal. There was no relief of pain with pharmacotherapy and physiotherapy. She could not attend her classes regularly due to back ache. On detailed evaluation in the adolescent clinic, she was diagnosed to have persistent somatoform pain disorder. She also had learning disorder and significant academic stress. The backache subsided completely after psychological therapy and there was no further relapse of pain.
7th standard student, presented with history of weakness of both lower limbs of 4 months duration. Detailed neurological evaluation and investigations were normal. On psychological evaluation, he was found to have academic stress, which had caused anxiety and emotional conflict leading to the conversion disorder in the form of lower limb paralysis. After giving psychotherapy, the power of lower limbs improved and he started walking normally within a few hours.
Somatoform Disorders
Physical symptoms that have no organic explanation are quite common in all medical settings. The tendency to communicate emotional distress in the form of physical symptoms is called somatization. Symptoms of patients with somatoform disorder are ‘real experiences’ and are ‘not imaginations’. Somatoform disorders are a broad group of illnesses in which the patients present with bodily symptoms suggestive of a physical disorder for which there are no demonstrable organic findings and for which there is strong evidence that the symptoms are linked to emotional stress or conflicts. The common somatoform disorders seen in adolescents are conversion disorder, pain disorder and somatoform autonomic dysfunction.
Conversion disorder
The patient presents with one or more symptoms affecting voluntary motor or sensory function that suggest a neurological disorder. The common symptoms in conversion disorder includes paralysis, sensory loss, aphonia, tremor, pseudoseizures, dizziness, blindness, deafness etc.
Persistent somatoform pain disorder
The person experiences persistent, severe and distressing pain, for at least 6 months in any part of the body. Those common symptoms are headache , backache, abdominal pain , chest pain and pain over extremities.
Somatoform autonomic dysfunction
The symptoms are presented by the patients as if they are due to a physical disorder of a system under autonomic innervation ie, Cardiovascular (palpitation, chest discomfort); Gastrointestinal (dyspepsia, irritable bowel syndrome, psychogenic vomiting or diarrhea) Respiratory system (psychogenic cough & hyperventilation) & Genitourinary system ( increased frequency of micturition or dysuria)
EVALUATION
We should exclude the factors which can negatively influence the learning ability of an adolescent, like family and school related stressors. Evaluation of learning disorder requires individually administered tests of intellectual ability and scholastic skills. Diagnosis is based on the presence of a significant discrepancy between the scholastic skills and the intellectual capacity of the individual. The IQ should be above 70. Other factors which can lead to scholastic backwardness like significant behavioral and emotional problems have to be excluded
TREATMENT
Intensive individually tailored one to one remedial training is the treatment of choice for learning disorders. Analysis of errors and development of an individual intervention plan, forms the mainstay of treatment for improving mathematical skills and writing skills.
Associated problems have to be managed adequately for getting optimal results. Behavior therapy is necessary in the management of comorbid Attention Deficit Hyperactivity Disorder. Motivational counseling and social skills training are needed for many teenagers. Parental guidance and family therapy also form important part of the management.
Adolescents with somatoform disorder require psychotherapy & relaxation therapy to manage anxiety related to the stress. Once anxiety is relieved, the physical symptoms will subside. Life skills training should be given to all adolescents to deal effectively with the stressors of life so that stress related disorders can be prevented.
CONCLUSION
The prognosis of learning disorder depends on the severity of the disorder, the age at which remedial intervention is started and the presence or absence of associated problems. Any student with speech delay, expressive language disorder or scholastic backwardness should be evaluated at the earliest to exclude learning disorders. If we start intensive remedial training at the onset of learning difficulty, learning problems can be remedied. By improving the motivation, self esteem, academic skills and life skills, we can guide the adolescents towards excellence in life.
