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.

Nice beautiful green coconut palm leaves from a village in Kerala, India.

Tdap vaccine

Tdap vaccine includes standard dose tetanus vaccine, reduced dose diphtheria vaccine and acellular pertusis vaccine. Standard DTP vaccine is not useful for children above 7 years of age.

Hepatitis B vaccination
 
WHO has recommended it for universal immunization.
 
Human papilloma virus vaccine [HPV]
 
16 and 18 are the important types of viruses involved in human cervical cancer. Vaccination of females before onset of sexual activity and before the age of 26 years.  
 
Varicella vaccination
 
If not exposed  earlier or wthin 72 hours of exposure [90 percent efficacy].
 
Japanese B encephalopalitis vaccination
 
Given in endemic areas

Acne – closed and open comedones. Macrolides have a high follicular concentration and are useful in the treatment of acne. Retinoids are also used frequently. Systemic antibiotics are also useful. Systemic retinoids should be used with caution. Comedone extraction is one of the common office procedures.

Hirsuitism if associated with metabolic syndrome should initiate a search for polycstic ovarian syndrome.

Seborrhoeic dermatitis is also androgen dependant and may sometimes be associated with metabolic syndrome.

Psychocutaneous disorders

Dermatitis artefacta
Prurigo nodularis – a form of neurodermatitis

BMI for adults:

Normal BMI: 18 – 25
Overweight: 25 – 30
Obesity: BMI 30 – 40
Morbid obesity: BMI > 40

To avoid obesity, ban eating in front of television. Food should be served only in the dining room. Encourage healthy eating habits and outdoor games. Bariatric surgery is only for the morbidly obese with comorbidity. On the preventive aspect, both low birth weight and high birth weight are to be prevented as they are fore runners of obesity. Obesity is the after effect of easy availability of inexpensive food and sedentary jobs.

Childhood autism was first described by Leo Kanner in 1943. He described 11 children who were “unable to relate” in usual ways to the people and considered it as autistic disturbances of affective contact. The term “autos” means self, and these children have a tendency to morbid self absorption.

Socioemotional reciprocity is the essence of human relationship and autism is a prototype disorder of sociocognitive development.

Prevalence of Autism

Recent studies have shown a prevalence rate 10 – 20 per 10000 children. The sex ratio of boys:girls is 4:1.

Etiology: Biological Factors

Abnormalities have been found in “social brain” – orbito-frontal and medial frontal cortex, superior temporal gyrus and limbic system – especially, reduced amygdala volume.

Relative increase in brain volume has been noted in MRI studies possibly due to failure of synaptic pruning. There is also reduced neuronal size in the hippocampus, amygdala, anterior cingulate cortex and mamillary bodies.

Diagnostic criteria

1. Qualitative impairment in reciprocal social interaction, characterised by:

Failure to develop appropriate peer relationships.
Marked impairment in multiple nonverbal behavior to regulate social interaction.
Lack of social or emotional reciprocity.
Lack of spontaneous seeking to share enjoyment, interests, and achievements with other people.

2. Qualitative impairment in communication as follows:

Delay in, or total lack of, the development of spoken language.
Impairment in the ability to initiate and sustain conversation with others.
Stereotyped or repetitive use of language.
Lack of varied, spontaneous play or social imitation of play.

3. Restricted repetitive and stereotyped behavior:

Stereotyped and repetitive motor mannerisms.
Persistent preoccupation with objects or preoccupation with one interest that is either abnormal in intensity or focus.
Inflexible adherence to specific, non-functional rituals or routines.

Along with the above primary symptoms of autism, these children have also have cognitive delays, motor delays and sensory difficulties.

Abnormalities of motor behaviour include hand flapping, waving in front of the eyes, tip toe walking and echopraxia. Echopraxia is the involuntary repetition or imitation of the observed movements of another individual.

Abnormal reponses to sensory stimuli include hyperacusis, tactile defensiveness – extreme sensitivity to touch or insensitivity to pain – may not cry after a severe injury.

Fascination to certain sensory stimuli such as spinning objects is common in autistic children. Some enjoy vestibular sensations such as twirling without becoming dizzy.

Savant skills in autism

10% of people on the autistic spectrum have savant skills. They have high, sometimes prodigious performance on a specific skill in the presence of mild or moderate mental retardation.
e. g. Memorizing lists, calender calculation, drawing skill, musical skill.

Atypical autism

Atypical autism is a type of pervasive developmental disorder that differs from childhood autism either in age of onset or in failing to fulfill all diagnostic criteria. Atypical autism manifests after the age 3 years or there are impairments in communication and stereotyped behaviour, but emotional response to caregivers is not affected.

Differential diagnosis of autism

Two other pervasive developmental disorders which come in the differential diagnosis include:

1. Asperger syndrome

Asperger syndrome was described by Asperger in 1944. It is characterized by the same kind of impairment of social activities and stereotyped features of behaviour as is described in autistic children.
There is no delay of speech and cognitive development. The condition occurs predominantly in boys (8:1).

2. Rett’s syndrome

Rett’s syndrome has been described only in girls. Normal early development is followed by partial or complete loss of speech and of skills in locomotion and use of hands, together with deceleration in head growth. Onset of Rett’s syndrome is between 7 and 24 months of age. Loss of purposive hand movements, hand-wringing stereotypies, and hyperventilation are the importan features of Rett’s syndrome. Motor functioning is more affected in middle childhood and muscles are hypotonic. Kyphoscoliosis and spasticity in the lower limbs occurs in majority of cases.

Other differential diagnoses of autism include selective mutism, receptive language disorders, expressive language disorders, mental retardation and obsessive compulsive disorder.

Assessment of autism

Developmental history is essential. Assessment of intelligence, self help skills and pre academic skills helps in planning the remedial training programs. Structured interviews like Autism Diagnostic Interview (ADI) and unstructured behavioral scales like Childhood Autism Rating Scale (CARS) and structured behavioral observation scales like Autism Diagnostic Observation Scale (ADOS)
help in arriving at a correct diagnosis.

Behavioural Analysis

Behavioural analysis should be done using ABC chart (antecedent, behaviour, consequence). Determine child’s current developmental level, strengths and weaknesses, likes and dislikes.

Treatment of autism

Early and intensive intervention is essential for successful management of autism. Medication is needed for children with aggressive behaviour. Behaviour modification programmes and social skills training and speech stimulation programs helps in improving the socioemotional reciprocity as well as communication skills of these children and helps in alleviating the stereotyped behaviours.

Conclusion

Identifying children with autism and initiating intensive, early ntervention during the preschool years, results in improved outcomes.