The Indian Journal of Pediatrics
https://doi.org/10.1007/s12098-019-03130-z
ORIGINAL ARTICLE
Children ‘At Risk’ of Developing Specific Learning Disability
in Primary Schools
Sri Lakshmi Chordia 1 & Kanimozhi Thandapani 1 & Arulkumaran Arunagirinathan 1
Received: 22 June 2019 / Accepted: 19 November 2019
# Dr. K C Chaudhuri Foundation 2019
Abstract
Objectives To study the proportion of children of age 5 to 7 y at risk of specific learning disability (SLD) and to analyse the sociodemographic risk factors.
Methods A school based cross-sectional study was conducted in six schools in Puducherry. Four hundred eighty students were
enrolled and study was conducted in a triphasic approach. Phase I- Screening by teachers using SLD-SQ (Specific Leaning
Disability – Screening Questionnaire); Phase II- Vision, hearing, and Intelligence Quotient (IQ) assessment were done in students
screened positive with SLD-SQ and those with vision or hearing impairment and subnormal intelligence were excluded; Phase IIIRemaining children were subjected to NIMHANS SLD index (Level I profile).
Results Of the 480 enrolled students 109 were screened positive with SLD-SQ. Twelve students were excluded in Phase II. Remaining
97 evaluated were evaluated with NIMHANS SLD index and 36 (7.5%) were screened positive. Boys (9.6%) were significantly more
affected than girls (4.9%). Similarly, risk was significantly higher in students of government schools (12.1%) than private schools (2.2%).
Ignoring punctuation and capitals was the commonest problem in SLD-SQ whereas, dysgraphia was most common in NIMHANS index.
Conclusions The present study shows though SLD is highly prevalent and remains undiagnosed due to lack of awareness among
teachers and parents. Since early intervention leads to better outcomes, Universal screening should be made mandatory and
remedial teaching centres made available, accessible and economical.
Keywords Learning disability . Dyslexia . Remedial teaching . Children
Introduction
Specific learning disability (SLD) is a neurodevelopmental
disorder that impedes the ability to learn or use specific
academic skills (e.g., reading, writing and arithmetic),
which is the foundation of other academic learning. The
learning difficulties are ‘unexpected’ in that other aspects
of development seem to be fine [1].
The prevalence of SLD in India ranges from 1.6%–15%
[2–5]. Exact etiology is not known but it is believed to be
predisposed by neurological impairment through genetic
transmission, developmental anomalies, perinatal insult or
malnutrition [6].
* Kanimozhi Thandapani
drkani88@gmail.com
1
Department of Pediatrics, Sri Manakula Vinayagar Medical College
and Hospital, Puducherry 605107, India
If learning disability goes undetected, child’s poor scholastic performance will bring in adverse impact on heath
related quality of life by causing poor self-esteem, disturbed
peer and family relationships, and unease social interactions
[7]. Unfortunately, in India many children remain undiagnosed because of lack of awareness among teachers, parents
and health staffs [8]. Also there is no standardized screening
protocol favouring early diagnosis or provisions for accessible consistent remedial teaching for intervention. Hence
the present study was conducted in primary schools in
Puducherry to find out proportion of children of age 5–7 y
‘at risk’ of developing specific learning disabilities and to
analyse the socio-demographic risk factors.
Material and Methods
This school based cross-sectional study was conducted in
six schools in Puducherry. Fourteen schools were located
within 5 km radius from the authors’ tertiary care centre. By
Indian J Pediatr
adopting lottery method of simple random sampling, 6
schools were selected. Sample size was calculated as 480
taking prevalence of SLD as 10% [9], confidence interval
95%, absolute precision 3% and 20% non-response rate.
After obtaining clearance from Institutional Ethics
Committee and permission from Deputy Director of
School Education, the study was initiated. All students of
age 5 to 7 y from the selected schools whose parents
consented were included in the study.
The study was conducted with a tri-phasic approach:
Phase I – Socio-demographic details of all students were
collected. Socio economic status was classified using
Modified B.G. Prasad classification (2018) [10]. Specific
learning disabilities – screening questionnaire (SLD-SQ)
was administered on all the enrolled students with the
help of the teachers. SLD-SQ was designed and standardized by Dr. Uday K Sinha at Institution of Human
Behaviour and Allied Sciences, copyrighted at 2015 by
psychomatrix; permission for its use was obtained from
the author. A cut-off score of four or more was considered
indicative of possibility of SLD. Sensitivity and specificity of questionnaire is 0.83 and 0.77 respectively for a
cut-off of four [11].
Phase II – Children screened positive with SLD-SQ,
underwent physical examination (for serious ailments that
might intrude with academic performance), vision, hearing
and Intelligence Quotient assessment.
Vision assessment was done using Snellen’s chart. Visual
acuity less than 6/60 was considered abnormal which is cutoff for low vision as per ICD 10 [12].
Hearing assessment was done using Tuning fork 512 Hz by
Rinne’s and Webers test. Sensitivity and specificity was 87%
and 100% respectively. Hearing was considered impaired if
either of the test was abnormal [13].
IQ assessment was done using Seguins Form Board. It is
a performance based tool that assesses the visuo-motor
skills, eye-hand coordination, visual and spatial perception,
cognition speed and accuracy in performing skills. IQ of 90
measured for chronological age was considered cut-off for
normal. Correlation with other tests like Malins Intelligence
scale for Indian Children and Vineland Social Maturity
Scale ranges from 0.31–0.50 [14].
Children who had visual or hearing impairment or subnormal intelligence were excluded from further evaluation.
Phase III – NIMHANS SLD index (Level I profile)
was administered to children who cleared Phase II assessment of the study. It consists of 8 components: Attention,
Visual discrimination, Visual memory, Auditory discrimination, Auditory memory, Speech and Language,
Visuomotor skills and Writing skills. Any child less than
8 y who doesn’t perform adequately is considered to have
specific learning difficulty or at risk for SLD. Test retest
reliability is 0.53 (p < 0.001) [15].
Phase II and III were done by a single investigator to avoid
bias. IQ assessment was done by clinical psychologist of authors’ Institute.
Data analysis was done using SPSS 24.0 software.
Variables such as socio-demographic characteristics, item
wise analysis of SLD-SQ, analysis of NIMHANS index
were represented in tables showing frequency and percentage. Logistic regression analysis was done to assess the
impact of gender, school sector and socio-economic status
on risk of SLD.
Results
The present study was conducted from September 2016
through October 2018. Four hundred ninety two students of
age 5–7 y studied in the selected schools. Twelve students
were excluded since parents did not give consent. Figure 1
shows the flow of subjects in the study. Majority of them
225(46.9%) were 6 y of age with 53.8% (258) boys and
46.3% (222) girls. Table 1 shows socio-demographic details
of students.
In Phase I, 109 (22.7%) children had a SLD-SQ score of
more than four suggesting possibility of having SLD of which
74 (67.9%) were boys and 35 (32.1%) were girls. This shows
higher screened positive male children, compared to female
children. In item wise analysis of SLD-SQ, ignoring punctuation and capitals was the commonest problem seen in
174(36.3%) of the students, followed by ineligible writing
133(27.7%). Table 2 shows item wise analysis of SLD-SQ.
In Phase II, Out of 109 SLD-SQ screened positive students, 9 had subnormal intelligence, 2 had hearing impairment, 1 had visual impairment and were excluded.
Remaining 97 children were assessed with NIMHANS
Total number of students of age 5-7 y in selected
schools (n=492)
12 excluded since parents did not give consent
Total number of students included in the study (n=480)
Phase I – Screened with SLD-SQ by teachers
109 screened positive
Phase II – Visual impairment (n=1), Hearing impairment
(n=2), Subnormal intelligence (n=9)
12 excluded
Phase III – NIMHANS SLD index – 36 students
identified at risk of SLD
Fig. 1 Flow of subjects in the study. SLD Specific learning disability
Indian J Pediatr
Table 1
Table 3
97)
Socio-demographic details of students (n = 480)
Characteristics
n (%)
Age (in years)
5y
6y
7y
Sex
Boys
Girls
School sector
Government
Private
Socio-economic status
Class I (Upper class)
Class II (Upper middle class)
Class III (Middle class)
Class IV (Lower middle class)
Class V (Lower class)
S. No
Items
n (%)
91 (19)
225 (46.9)
164 (34.2)
1.
2.
3.
4.
Writing skills
Visual discrimination
Auditory behavior
Auditory memory
35 (36.1)
13 (13.4)
12 (12.4)
10 (10.3)
258 (53.8)
222 (46.3)
5.
6.
7.
8.
9.
Auditory discrimination
Visual discrimination
Attention
Visuomotor skills
Verbal language expression
9 (9.3)
6 (6.2)
5 (5.2)
3 (3.1)
0
255 (53.1)
225 (46.9)
n No. of students evaluated with NIMHANS SLD index
8 (1.7)
62 (12.9)
241 (50.2)
141 (29.4)
28 (5.8)
n No. of students enrolled in the study
SLD index (Phase III) and 36 students (7.5% of study population) were found to be at the risk of SLD.
In item wise analysis of NIMHANS SLD index, most of
the affected children had difficulty in writing skills
[35(36.1%)], followed by impaired visual discrimination
[13(13.4%)], poor auditory behavior [12(12.4%)] and inadequate auditory memory [10(10.3%)]. Table 3 shows item wise
analysis of NIMHANS index.
Analysing the association of socio-demographic factors
with risk of developing SLD, it is evident that gender has
statistically significant association (p 0.02) with 9.6% of boys
being affected compared to 4.6% girls. In socio-economic
grounds, 8.3% children from lower socio-economic status
(SES) were at risk while only 1.6% from high SES were at
Table 2 Item wise analysis of
SLD-SQ (n = 480)
Item wise analysis of NIMHANS index (Level I profile) (n =
risk, yet there was no statistical significance (p 0.48).
Comparing school sector to SLD risk status, 12.1% children
from government schools were at risk but only 2.2% from
private schools were at risk. The association was found to be
statistically significant (p 0.000) (Table 4).
Discussion
The present study was conducted in six schools in
puducherry. Three government and three private schools
were included to study the differences in prevalence and risk
factors. Age group 5 to 7 y was chosen since the age of
identification plays a major role in outcome of the child.
The screening and assessment tools used were SLD-SQ
and NIMHANS SLD index respectively. These tools are
recommended by the recent Indian Academy of Pediatrics
(IAP) consensus on evaluation and management of learning
disability [16].
In the present study, the proportion of children at risk of developing specific learning disability was found to be 7.5%. This
S. No
Item
n (%)
1.
2.
3.
4.
5.
6.
7.
8.
9.
10.
11.
12.
Ignore capitals or punctuation while writing
Writes in ineligible writing
Difficulty in differentiating similar sounding words
Gets confused in mathematical symbols
Forget lessons easily
Misplaces words or letters while reading or writing
Makes mistakes in solving math problem
Makes frequent mistakes in spelling while reading or writing
Miss out words or sentences while reading
Difficulty in understanding what is taught in class
Overall academic ability much below his/her grade level
Difficult to make down what is written on the board
174 (36.3)
133 (27.7)
126 (26.9)
126 (26.3)
126 (26.2)
124 (25.8)
123 (25.6)
121 (25.2)
103 (21.5)
89 (18.5)
74 (15.4)
48 (10)
n Number of students enrolled in the study
Indian J Pediatr
Table 4 Association between
socio-demographic variables and
SLD risk status
Variables
Gender
Boys (n = 258)
Girls (n = 222)
Socio-economic status
High (Class I, II, III)
(n = 60)
Low (Class IV, V)
(n = 420)
School sector
Private (n = 225)
Government (n = 255)
Odds
ratio
95% Confidence
Interval
P
value
233 (90.3%)
211 (95.1%)
0.407
0.190–0.871
0.02
1 (1.6%)
59 (98.3%)
1.33
0.593–3.006
0.485
35 (8.3%)
385 (91.6%)
5 (2.2%)
31 (12.1%)
220 (97.8%)
224 (87.8%)
0.179
0.071–0.450
0.000
At risk of
SLD
No risk of
SLD
(n = 36)
(n = 444)
25 (9.6%)
11 (4.9%)
p < 0.05 is considered statistically significant
finding is closely in consistence with a study conducted at Andhra
Pradhesh in 2017 by Bandla et al. (6.6%) [17]. However, it is
relatively low when compared to studies conducted by
Mogasale VV (15.17%) at Karnataka in the year 2014 and
Sridevi et al. (19%) in Hyderabad (2015) [5, 18]. Analyzing various other studies, range of SLD prevalence can be given as 6.6%
to 19% in South India [5, 17–20] and 1.58% to 12.8% in north
India [2–4, 21–23]. These studies had heterogeneity in sample
size, sampling technique, screening tool used, method used for
assessing SLD, study setting, study population and environmental
background which explains variation in the prevalence figures.
The present study showed statistically significant gender difference with boys (9.6%) being affected twice more than girls
(4.9%). According to Diagnostic and Statistical Manual of
Mental Disorders (DSM-5), learning disability is two to three
times more prevalent in boys than in girls [1]. In an article published in JAMA that includes four large epidemiological studies
on sex differences in SLD with almost 10,000 participants, it is
clearly evident that SLD is substantially more common in boys
[24]. A genetic research on X-chromosome has unravelled nine
new genes, which because of their location on X-chromosome,
are known to affect predominantly males [25]. Also physiological differences between males and females like developmental
lag in childhood, biochemical (boys are resilient to proteins), and
neonatal differences (hormonal milieu – more exposure to androgen in boys) could play a role [26].
Similarly, students from government schools (12%) were
more at risk compared to private school students (2.2%) and
there was statistical significance. Lack of adequate training,
perhaps due to late admission age, poor parental supervision
and involvement could be contributing factors.
Regarding socio-economic status, 8.3% children from lower socio-economic status were at risk while only 1.6% from
high SES were at risk, yet there was no statistical significance.
Similar finding was noted by Padhy et al. [2]. Karande and
Bandla et al. stated a high prevalence rate of SLD among high
and upper middle socio-economic class [7, 17]. The study
settings in these studies were from private remediable clinics
whose parents are expected to be economically affordable.
With item wise analysis of SLD-SQ, ignoring punctuation
and capitals was the commonest problem, followed by ineligible writing. Padhy et al. also used SLD-SQ to screen for
SLD [2]. They found missing out words or sentences while
reading to be the commonest issue followed by, misplacing
letters or words while reading or writing.
With item wise analysis of NIMHANS index, 36.1% had difficulty in writing (dysgraphia), followed by impaired visual discrimination in 13.4% and poor auditory behavior in 12.4%. Since
age group included in present study is 5 to 7 y, Level I profile is
used and if any child does not perform adequately, he/she is considered to have specific learning ‘difficulty’, not disability.
Neuronal circuitry is constantly reconstructed in response to experience. Hence effective early intervention can potentially bring
in compensatory mechanisms to bridge functional gaps [27].
During the course of study, authors observed that the
awareness of teachers on SLD was limited. Kamala et al. conducted a study among teachers in Puducherry and found that
their understanding on SLD is sparse [28]. Padhy et al. also
reported the same [29].
Strengths of present study are use of standardised screening
and assessment tools. Not many studies have been conducted
in 5–7 y age children to identify those ‘at risk’ and this is first
such study in the region.
The use of NIMHANS index in English could have led to
overestimation of prevalence in government schools. Also
clustering of schools in one region is a limiting factor in
generalising the results to whole of Puducherry. The association of other psycho-behavioral conditions were not looked
for in the participants. Those identified ‘at risk’ need reassessment at 8 y since few maybe ‘normal late developers’.
Indian J Pediatr
Conclusions
10.
The authors found a proportion of 7.5% children, belonging to
age group of 5 to 7 y to be ‘at risk’ of developing SLD with
significant male predominance. Teachers and pediatricians
should be made aware of early signs of SLD. Screening tools
need to be standardised and made available in all vernacular
languages. Also universal screening for LD should be made
mandatory and remedial centres made accessible and economical. This promotes early identification and intervention,
which is crucial to optimise learning and prevent secondary
emotional problems. More longitudinal studies on large scale
focussing on intervention strategies would help in standardizing the management protocols for such children.
11.
Acknowledgements The authors would like to thank the School teachers
who helped them in screening children with SLD-SQ score and Dr.
Sindhuri, Assistant Professor, Community Medicine, Sri Manakula
Vinayagar Medical College and Hospital for statistical analysis.
12.
13.
14.
15.
16.
17.
Authors’ Contribution SLC collected the data, reviewed the literature and
drafted the manuscript. KT and AA conceptualized the study, reviewed
the literature and critically reviewed the manuscript. All authors contributed to writing the paper and approved the final version of the manuscript.
AA is the guarantor for this paper.
19.
Compliance with Ethical Standards
20.
Conflict of Interest None.
21.
18.
22.
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