Learning disorders Nursing Perspective

1 | Bivin,J.B (2010). Nursing Care Of Children With Learning Disorders, Dept. Of Psychiatric Nursing, NIMHANS

1. Introduction:1. Introduction:1. Introduction:1. Introduction:

‘Specific developmental disorders of scholastic skills' (ICD-10) or ‘Learning disorders' (DSM-IV) include

disorders characterized by one or more significant impairments in acquisition of reading, spelling, or arithmetical skills.

ICD-10 suggests that the category ‘Mixed disorder of scholastic skills' (F81.3) be used as an ill-defined, but necessary,

category in which arithmetical and reading or spelling skills are significantly impaired, although not because of general

mental retardation or inadequate schooling.

The national joint committee on learning disabilities (NJCLD, 1998) has defined learning disorders as “…… a

heterogeneous group of disorders manifested significant difficulties in the acquisition and use of listening, speaking,

reading, writing, reasoning or mathematical abilities. These disorders are intrinsic to the individual, presumed to be due

to central nervous system dysfunction, and may occur across the life span. Problems in self regulatory behavior, social

perception, and social interaction may exist with learning disorders. Although, learning disabilities may occur

concomitantly with other handicapping conditions, (e.g. sensory impairment, mental retardation, serious emotional

disturbances) or with extrinsic influences, (e.g. cultural differences, insufficient or inappropriate instruction)”

The disorders classified in the category ‘Specific developmental disorders of scholastic skills' (SDDSS)

resemble specific disorders of speech and language. As in these latter disorders, normal patterns of skill acquisition

are disturbed and detectable at an age when these functions are required. The disorders are not due to a lack of

opportunity to learn or a consequence of brain trauma or disease, but represent a specific type of dysfunction in

cognitive processing. The dysfunction affects specific skills, which can be distinguished from the cognitive functions

that are usually in the normal range. As in other specific developmental disorders, the condition is more common in

boys than in girls.

ICD-10 notes five difficulties regarding diagnosis and differential diagnosis:

→ Differentiation of the disorder from normal variations in scholastic achievement (this problem applies to all

specific developmental disorders and was discussed in relation to specific developmental disorders of speech

and language);

→ Consideration of the normal developmental course;

→ Interference with learning and teaching;

→ Underlying abnormalities in cognitive processing;

→ Uncertainties over the best way of sub differentiating SDDSS.

Based on these considerations, the following diagnostic guidelines for all SDDSS have been suggested (ICD-10):

∼ Clinically significant degree of impairment: this is judged on the basis of severity (e.g. occurrence in less

than 3 per cent of schoolchildren), developmental precursors (e.g. speech or language disorder in preschool

years), and associated problems (e.g. inattention).

∼ Specific impairment not explained solely by mental retardation or by lesser impairments in general

intelligence: for this requirement to be met, individually administered and standardized IQ scholastic

achievement tests are obligatory to demonstrate that the child's level of achievement is substantially below the

expected level compared to a child of the same mental age.

∼ Developmental nature of the impairment: this must be demonstrated by the presence of the disorder during

the early years of schooling and by exclusion of impairment acquired later. The child's history of school

progress is decisive in this respect.

∼ Absence of external factors that could explain the impairment: SDDSS are thought to be mainly based on

factors intrinsic to the child's development, and not due to inadequate schooling or any other environmental

factors such as absence from school or educational discontinuities. However, such conditions may occur,

making the diagnostic process difficult.

∼ Exclusion of visual and hearing impairments: by definition, SDDSS do not occur as a result of impairment

of sensory function, such as visual or hearing impairment.

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Children with learning disorders constitute the largest and fastest growing population of special needs in children in

schools. Epidemiological research reveals that the prevalence of LD ranges between 5-15% (Harris, 1995). In Indian

context, prevalence estimate ranges from 9-39% (Agarwal, Agarwal Upadhyay & Singh, 1991; Kapur etal., 1995). The

incidence of dyslexia in primary school children in India has been reported to be 2-18% and of dyscalculia, 5.5%

(Choudhay, 2005; Ramaa, 2000)

2. Specific2. Specific2. Specific2. Specific Reading DisorderReading DisorderReading DisorderReading Disorder (Dyslexia)(Dyslexia)(Dyslexia)(Dyslexia)

2.1. Clinical features

The main feature of this disorder is a specific and significant impairment in the development of reading skills,

which is not solely accounted for by mental age, visual acuity problems, or inadequate schooling. Other functions may

also be affected: reading, comprehension skills, reading word recognition, oral reading skills, and performance of tasks

requiring reading.

2, 2.Co morbidity and associated features

Several associated disorders been observed through longitudinal studies like, emotional problems during the

early school years; hyperactivity and conduct disorders in later childhood and adolescence. Additional frequent

features include low self-esteem, adjustment problems at school, and problems in peer relationships. In about 40 per

cent of children with reading and/or spelling disorder, other disorders of clinical relevance are present.

2.3. Epidemiology

Specific reading and spelling disorder occur in about 4 per cent of 8- to 10-year-old children, with

predominance among boys (2:1).

2.4. Aetiology

Converging evidence from cognitive, neuroimaging, and genetic studies indicates that reading disorders is a

neurobiological disorder with a genetic origin. It is thought to be related to a deficiency in a specific component of the

language system for processing sounds of the spoken language. This deficit in turn gives rise to difficulties in decoding

(reading) and coding (writing or spelling). Currently, four main aetiological factors have been discussed:

� Genetic influences: earlier twin studies report concordance rate of about 100 percent for monozygotic twins

and 35 percent for monozygotic twins, wherein recent studies found lower concordance rates. With regards to

family studies, there is ample evidence that reading and spelling disability show high recurrence in first degree

relatives.

� Deficits in central information processing: brain studies indicate that there is a suggestive maturational lag of

the left hemisphere in poor readers or difficulties with inter-hemispherical transfer. In addition, the

abnormalities involved in planum temporal, said to show more symmetry in reading disabled.

� General psychosocial factors: influences of these factors seem to be more marginal than compared to other

factors. Specific learning conditions and psychosocial factors go hand in hand and mostly interacting with each

another.

2.5. Management

2.5.1Principles of Management

• Treatment should start as early as possible in order to avoid a sense of failure and low self-esteem.

• The treatment should focus on individual instruction and teaching sessions in basic phonetic and other skills

such as reading, spelling, and writing. This needs to be done in an age-appropriate way based on the

principles of learning theory and starting at a very low level to avoid disappointment and a sense of failure.

• Even when feelings of failure and, consequently, low self-esteem are present, the instruction in basic skills is

the appropriate approach. The child's psychological and learning situation deserves special attention.

Psychotherapeutic measures alone are not successful.

• Parental support is extremely important. Therefore, the parents should not only be educated in detail about the

disorder, but also encouraged to listen to their children reading from school books. This has been shown to be

a successful approach.


• There is no specific medication to improve reading and spelling skills, but there is some indication that

stimulants may be helpful for poor readers who simultaneously suffer from attention-deficit hyperactivity

disorder. Some studies have tested the nootropic substance piracetam and found it useful in improving

reading comprehension and reading speed.

2.5.2 Exercise in Reading

High interest / low vocabulary materials

Child with reading problems is often frustrated with reading materials because books geared to their interest level

are beyond their reading ability. Therefore books that are designed to be of high interest yet at an easier level are to be

used.

Multisensory Method

Reading approaches that are labeled multisensory usually attempt to teach reading skills through kinesthetic

and tactile stimulation along with the visual and auditory modalities. Two methods of teaching that emphasizes a

multidisciplinary approach are:

Fernald method known as whole word approach. It involves four stages as follows,

1. The student select a word, which is written in large letters in a flash card. The student traces the word with his

finger and is instructed to say it aloud as it is traced. The student repeats this process as often as necessary

until the word can be written as a unit from memory. Each new word that the student learns is filed

alphabetically and these words are frequently utilized in stories.

2. This is identical to stage 1 except that tracing is eliminated.

3. Here words are no longer written on the cards

4. This stage encourages the child to learn new words from generalizing from words already known, to survey a

reading passage and pick out new words and learn.

Gillingham Approach

This method is known as phonic method. Phonetic drill cards are used

1. A small card with one letter printed on it is exposed to the child and the name of the letter is spoken by the

teacher. The name of the letter is then repeated by the child.

2. As soon as the name of the letter is mastered, its sound is made by the teacher and repeated by the child. The

original card is then exposed and the teacher asks “what does this letter say?” the child is expected to give the

sound.

3. Without the card exposed, the teacher makes the sound represented by the letter and says “tell me the name

of the letter that has this sound” the student is expected to give the name of the letter.

4. The letter is then written by the teacher and its form is explained to the child. That letter is then traced by the

child, copied, written from memory and then written again looking at it.

5. Finally the teacher makes the sound and instructs the child to write the letter that has this sound.

Programmed reading

Most programmed reading materials are designed to teach reading skills through a concisely organized and sequential

approach. In reading most programmed take place in the form of work book. The children usually ask to complete the

materials at their own pace.

Remedial reading drills.

The programs consist of lists of words emphasizing specific sounds and combination of letters. The child is instructed

to use various lists to learn to blend various sounds. Drill exercise is used to reinforce the sound symbol relationship.

3. Specific3. Specific3. Specific3. Specific Spelling DisorderSpelling DisorderSpelling DisorderSpelling Disorder


In ICD-10, the main characteristic of this disorder is a specific and significant impairment in the development of

spelling skills in the absence of a history of specific reading disorder, which is not solely accounted for by low mental


age, visual acuity problems, or inadequate schooling. The children have difficulties in spelling orally and writing words

correctly. The spelling difficulties should not be due to grossly inadequate teaching, to sensory deficits, or to

neurological disorders or dysfunctions. They should not be acquired, either as a result of neuropsychiatric or any other

disorders.

3.2. Interventions

The nurse can teach either the parent or the teacher of the child considering to the setting where she

practices. The basic strategies that a nurse could teach are as follows;

1) Write and say a word while the child watches and listens.

2) The student traces the words while simultaneously saying the word. Then on careful pronunciation, with each

syllable of the word dragged slowly as it is traced or written.

3) Next the word is written from memory. If it is incorrect, step 2 is repeated. If the word is correct, it is put in a file

box. Later the words in a file box are used in stories.

4) At late stages;

a. No need for tracing

b. Child learns the word by observing the teacher or parents and says it and then he writes and says it

himself.

c. He learns the word by looking at it in print and writing it and finally merely looking at it.

d. Show child’s wrong spelling written down, then show correct spelling.

e. Especially for words that do not follow regular phonetics rules words for which the child must use

visual memory.

5) Parental counseling

Help the parent to accept the child as such and make them understand that it is a sickness and not because of

their laziness or lack of interest in studies. It can be managed only by proper guidance and tender care of those

handling the child. The micro-gains of the child to be appreciated and reinforced appropriately

6) Counseling and psychotherapy of the child:

� Positive reinforcement given immediately and contingently can accelerate the learning of reading skills

� Provide feedback of results such as rewards

� Allowing child to plan their own program

� Help with the emotional issues that arise from struggling to overcome academic difficulties

� Handle these children with care and never belittle them in front of others

� The child’s interests and talents to be taken into account while planning for remedial education

6. 6. 6. 6. Specific Writing Disorder Specific Writing Disorder Specific Writing Disorder Specific Writing Disorder

Disorder of written expression is a condition diagnosed in childhood that it characterized poor handwriting

skills that are significantly below what is normal considering the child’s age, intelligence, and education, and that cause

problems with academic success or other important areas of life.

6.1. Prevalence & causes

The prevalence of writing disorder has not been studied systematically, and it is generally assumed to be similar to the

prevalence of reading disorders (4%), in India, the prevalence is 14%. The cause of this is idiopathic. A range of

neuropsychological, genetic, and perinatal environmental factors has been postulated.

6.2. Co Morbidity and Associated Features

Other developmental disorders of childhood frequently occurs with writing disorders including motor skill disorders,

communication disorders, mental retardation, and ADHD, the most occurring psychiatric disorder.

6.3. Interventions

Preventive nursing approach of providing instruction in handwriting and composition in kindergarten and

primary grades, particularly for children who are already are risk at developing this problem. The inclusion of

mnemonics (e.g. POWER for Plan, organization, write, edit and revise).


Some exercises in written expression that a nurse can include in daily scheduling for caring children with

specific writing disabilities are as follows; encourage spontaneous writing, functional writing, conveying information in

structured form, story writing, and wordless picture book. Some exercises in writing (readiness activities) like, body

exercise to practice hand movements, scissor works, coloring tasks, practice drawing circles, finger painting, clay

modeling, black board activities, etc. could be encouraged by the nurse in a clinical settings and even the parents been

asked to be involved these structured activities to their child’s need.

5555. Specific. Specific. Specific. Specific Disorders of Arithmetical SkillsDisorders of Arithmetical SkillsDisorders of Arithmetical SkillsDisorders of Arithmetical Skills


The impairment mainly affects basic computational skills of addition, subtraction, multiplication, and division,

whereas other functions such as reading and writing or motor skills are within the normal range (except in mixed

disorder of scholastic skills). The arithmetical difficulties vary, but in most cases include the following features (ICD-

10):

♦ Difficulties in understanding the concepts underlying arithmetical operations

♦ Difficulties or lack of understanding of mathematical terms or signs

♦ Difficulties in recognizing numerical symbols

♦ Difficulties in carrying out arithmetical manipulations

♦ Difficulties in aligning numbers or symbols when performing calculations

♦ Poor spatial organization of arithmetical calculations

♦ Reduced ability to learn multiplication tables satisfactorily.

5.2. Epidemiology

It is estimated that between 0.5 and 1 per cent of all schoolchildren suffer from a specific arithmetical disorder.

There is evidence that about 1.3 per cent of 9- and 10-year-old children suffer from specific arithmetical difficulties, and

that a further 2.3 per cent have combined difficulties in arithmetic and reading. The sex ratio is approximately equal

5.3. Aetiology

Arithmetical disorders have not been studied with the same intensity as reading and spelling disorder.

Therefore, knowledge about aetiology, course, and outcome is limited. There are, however, some hints that children

with this disorder tend to have impaired visuospatial and visuoperceptual skills, whilst verbal and auditory–perceptual

skills seem to be within the normal range. A substantial proportion of children with specific disorder of arithmetical skills

have associated emotional problems and difficulties in social interactions.

5.4. Treatment

The treatment of specific disorders of arithmetical skills follows the same general lines as treatment of specific

reading disorder. All treatment components have to focus on the training of skills that are impaired in a way that keeps

the child motivated. Effective educational techniques for children with mathematics disorders are those incorporate

modeling and feedback procedures, reinforcement to acquired arithmetic skills, a concrete to abstract teaching

sequence, think-aloud procedures (ie, verbalization while problem solving), creative strategies and mnemonics to

facilitate recall of sequential problem solving strategies, frequent monitoring of child’s progress, and teaching skills to

mastery.

Teaching arithmetic skills include, which the nurse can effectively teach either the parent or the school

teachers are as follows and this can be done at different levels as explained following, concrete level; using the blocks,

beads, straws etc., semi concrete level; cutting equal sizes sticks in to halves., abstract levels; here multiplication,

addition, subtraction, etc. can be given.

The provision of small group tutorial to teach to mastery appears to be an effective approach. Mathematics

anxiety requires a more psychotherapeutic approach using relaxation techniques, with the aim of reducing anxiety prior

to and during maths lessons in order to avoid a sense of failure.

6666. Mixed. Mixed. Mixed. Mixed disorders of scholastic skillsdisorders of scholastic skillsdisorders of scholastic skillsdisorders of scholastic skills

In ICD-10, this is specified as an ill-defined and inadequately conceptualized, but necessary residual, category

of disorders in which both arithmetical and reading or spelling skills can be significantly impaired, and in which the


disorder cannot be explained in terms of general mental retardation or inadequate schooling. This category covers

disorders that meet the criteria of ‘Specific disorder of arithmetical skills' (F81.2) and either ‘Specific reading disorder'

(F81.0) or ‘Specific spelling disorder' (F81.1). As has been explained earlier, in the case of a mixed disorder of

scholastic skills, it is specific arithmetical disorder that seems to dominate both in severity and with respect to

associated psychopathological features.

7. Preventing Specific Learning Disorders 7. Preventing Specific Learning Disorders 7. Preventing Specific Learning Disorders 7. Preventing Specific Learning Disorders

The preventive strategies start by educating the parents/ primary care givers/ school teachers about the

following;

• Teachers/ parents play an important role in the identification of these children because the primary

manifestation of this illness is the everyday coping inabilities of the child in his academic expectation. The

parents or the teacher can monitored the child’s performance and involvement in the class room or home

based study activities.

• Identify and foster the child’s abilities instead of repeatedly stressing the weakness. Accept the child as he is

and avoid unnecessary punishments and comparisons.

• Ill treatment or labeling them as being stupid or lazy can lead to secondary symptoms like emotional problems,

reduction in self esteem, behavioral problems and high suicidal risks.

• Mental input in school plays a major role in the amelioration of learning problems in children.

• The teachers could help the child with positive school climate, classroom management, services and

strategies to maximize the success.

• Positive attitude and perceptions about learning are key elements of effective instruction.

8888. Conclusion. Conclusion. Conclusion. Conclusion

Significant difficulties continue to bedevil the definition of Learning disabilities, including problems surrounding

various criteria such as an IQ/learning discrepancy or low absolute achievement level. The high degree of comorbidity

with many psychiatric disorders raises further issues for studies requiring a homogeneous symptom pattern, and it

seems likely that further advances will require replacing broad clinical patterns with more specific processing deficits.

Despite these limitations, much of the pharmacologic work has been confounded by the comorbidity of Learning

disabilities with ADHD and other childhood disorders. Evidence generally supports the finding that psychostimulants

have positive effects on immediate learning performance but less impact on long-term academic gains. Learning

disability remains a large public health problem, are significantly undertreated, have devastating lifetime outcomes,

and therefore merits greater care and responsible treatment needs.

9999. References. References. References. References

Brian Lask, Sharon Taylor and Kenneth P. Nunn (2003) Practical Child Psychiatry; The Clinician’s Guide, 1st Ed.,

London: BMJ Publishig Group.152-175

Harris, (1995), Developmental Neuropsychiatry-Assessment, Diagnosis and Treatment of Developmental Disorders, NY: Oxford University Press. 123

Keith C. Conners & Ann C. Shulte, Learning Disorders, Retrieved from http://www.acnp.org/Docs on 2010. 07. 21

Michael G. Gelder Juan J. Lopez-Ibor, Nancy Andreasen & Jaun J. Lopez-Idor(Eds.)(2003), New Oxford Textbook of Psychiatry, 4

th Ed., Vol. 01, London: Oxford university Press. 1347-1352

Padmavathy, D, Lalitha, K & Hirisave, U (2009), Information Booklet On Management Of Learning Disability In School Children, Unpublished Dissertation. Department of Nursing, NIMHANS. Bengaluru

Sadock Benjamin James & Sadock Virginia Alcott (2007), Kaplan and Sadock’s Synopsis of Psychiatry: Behavioral Sciences/ Clinical Psychiatry, 10

th Ed., New Delhi: Wolteres Kluvers India (Pvt.) Ltd. / Lippincott Williams and Wilkins-

South Asian edition. Ch. 39

Sheena Reynolds & Chris Reynolds. Learning difficulties: Reading the Signs, Retrieved from http://www.british-ild.com/downloads/articles/learning-difficulties.pdf on 2010. 07.20

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Learning disorders Nursing Perspective