Dyslexia

Dr.V. SIVAPRAKASAM, MD, DCH ,PGDN, PGD-AP ,FIAP.

National Trainer on Learning Disability & Project coordinator & Faculty (Trainer)
President IAP Tamil Nadu 2012
National EB Member of IAP 2014,2015,2017
Director Nataraja Children’s hospital and Nataraja Child Development Centre,
Chidambaram

Abstract: Specific learning disability, is a neuro-developmental and biological disorder

which refers to ongoing problems in reading or writing or mathematics . Reading difficulty in
a child with normal or above normal IQ, is considered as ‘dyslexia’, writing difficulty as
‘dysgraphia’ and difficulty in mathematics as ‘dyscalculia’. Remedial teaching remains the
mainstay of management. Specific learning disability is included in the disability act and
children with dyslexia get free remedial teaching and concessions in education by the
Government. Early identification of specific learning disability and prompt intervention will
result in bright future for these children.

Introduction

Learning problem in children is increasingly recognized among the community in India.

Early identification of Learning disability is absolutely vital as early remediation and intervention,
has the best chance of, favorable outcome. Learning disability affects 5 – 15 % of school
children. That amounts to, huge numbers and it is estimated that today, this involves over 2.8
million school children. The human and financial implications of, poor academic performance, in
children, to the society, is staggering. In addition, the distress it causes to child, the parents and
the school is considerable. Scholastic backwardness has a lifelong impact on the child, as it
affects the child’s self esteem, higher education, employment opportunities, interpersonal
relationships, marriage and almost every other sphere of his/her life.

Estimates from surveys in the schools, show that 20% of school children, are
underachievers and of the 50% of those having an underlying neuro-developmental cause, a
large percent have the invisible disability called Specific Learning Disability, for which we could
offer remediation and medications, in selected cases, to ensure their mainstreaming, so that
they become, useful citizens of our society. 

Dyslexia is a disorder in children, who despite conventional class room experience, fails
to attain the language skills, of reading, writing & spelling, commensurate with their intellectual
abilities. Dyslexia is a disorder manifested by, difficulty in learning to read, despite conventional
instructions & socio cultural opportunity. These Children, will have lot of grammar mistake, Lot
of spelling mistake, slow reading, reversal tendency in reading and writing. (Read “was” as
“saw”) .These children, can be identified, at the age of 7 years. Their IQ is normal or above
normal. Government is giving, lot of Concessions to these children. Remedial Teaching is the
main mode of management of these Children. When we identify, them early and give remedial
measures and get the government concessions, they will be able to perform well in studies and
pass 12th Standard and may become post graduates and Professionals .If we fail to identify
them early they get lot of problems likeRepeated failure, Rejection, Poor self esteem, Anxiety,
Disturbed, Insecure, Joker of the class, Delinquency, School drop outs, Become social misfits.

Aims and Objectives of IMA

1. To create Awareness among Doctors, Teachers and Public about Dyslexia

2. To train teachers, for detection of LD
3. To Train the IMA Doctors on Screening for LD by using a simple Tool
4. To identify the prevalence of learning disability in Tamil Nadu State
5. To identify the causes of learning disability
6. To Screen the Children in Medical college to arrive at a Final Diagnosis
No child wantonly fails in class. There should be some reason for it. when child comes with
scholastic performance below par we need to identify the cause for it.

Medical problem -vision, hearing Hypothyroid state, Chronic illness like Asthma CRF.CHD, etc.
Brain should function Normally, Intellectual Disability is very common due to No Detention
Policy, AHDH is one more condition. Home atmosphere, and School atmosphere should be
normal. Child should have motivation to study. Some Psychological Problems like Depression,
Anxiety may be the cause for poor performance. If we r/o all the above conditions we need to
consider Dyslexia.

What is Dyslexia? f An Intelligent Child who fails in a class. Normal or Above Normal IQ
100-140%. Not performing well in School. Dislike reading, read slowly, skips words, sentences,
Reversal tendency---- was-saw. Righting slowly- Poor Hand-righting. Lot of Spelling and
Grammar mistakes. Poor in math

Definition: SpLD is a group of neuro-developmental disorder manifesting as persistent

difficulty in learning to efficiently read (dyslexia),write (dysgraphia)and perform mathematical
calculations (dyscalculia) despite normal intelligence conventional schooling, intact hearing and
vision, adequate motivation and socio-cultural opportunity.

IAP Guideline definition: (5)

Learning disabilities (LD) are a heterogeneous group of disorders where the individual

unexpectedly fails to competently acquire, retrieve and use information. The academic
achievement is lower than expected, based on the child’s overall intelligence. LD has been

defined as a neurodevelopment disorder of biological origin manifesting in learning difficulties

and problems in acquiring academic skills, which are markedly below age level.

1. Dyslexia - Difficulty in reading:

It is caused by deficit in Phonological processing (5). Children with Dyslexia reads very slowly,

word by word, losses place, missing out lines or reading the same line again. Therefore needs

to always keep finger below line being read. They hesitate to read aloud, hates reading and

refuse to read. These children may try to sound out the individual elements of word, but is often

unable to synthesize it into the correct word. E.g. b/e/g and then say bad(9).

Other Presenting features are:

Ignores punctuation, thus often confusing the meaning of the text.

Confusion with alphabet, shapes and positions b as d (9)

Confusion in words -- was - saw( mirror image reading)

Omission bet for belt ,wet for went

Addition played for play

Substitution house for home

Mispronounces some words such as:- help for held

Puts syllables in the wrong order:- animal as aminal

They answer well in oral, but fails in written tests. They are unable to tell a story.and

have difficulty in explaining with examples. Sounds are confused empty- entry. These children

have poor memory- cannot recall sequence of letters [inefficient visual memory system]- no

automatic reading. Concepts are reversed- Floor for ceiling

Reading Comprehension:
 There is difficulty in understanding the meaning of what is read (e.g. may read text

accurately but not understand the sequence, relationships, inferences, or deeper meanings of

what is read). and. poor in reading comprehension. There will be difficulty in reading and

understanding questions and if we read out question, the child can answer. Understands and

learns better if someone reads out the same text to the child

II. Dysgraphia- Writing disability:

It is caused by a range of neurodevelopment weakness including problem with hand

writing (fine motor & grapho motor) and visual -spatial perception.

Dysgraphia is often multi-factorial, due to impaired letter writing automaticity, finger

motor sequencing challenges, organizational and elaborative difficulties and impaired visual

word form which makes difficult to retrieve the visual of words requiring spelling.

Here the problem exclusively in spelling (also called encoding which is ability to use letter

sound relationships effectively) in the absence of problem in written expression is more

indicative of phonological processing deficit ie Dyslexia. (5,7)

These children will have Poor handwriting and abnormal grip makes writing slow and laborious,

notes are incomplete and do not make sense. These children are poor in remembering certain

alphabets and unable to copy from board. Shows mirror writing. They do lot of spelling mistakes

and grammar mistakes.

Writes letters in the wrong order e.g. Simon as Siomn, what as wtah

Inconsistent errors/sometimes correct spelling - e.g. apple, appel, aple (9)

Reverses letters and words - e.g. b as d, p as q, was as saw (mirror image writing)

Inverts letters - e.g. n-u, m-w, d-q, p-b, f-t

Omits letters - e.g. limp as lip, string as sing

Adds letters - e.g. went as whent, what as whant

Spells the way the word sounds - BUSY as BIZZY

III. Dyscalculia- Difficulty with mathematics:

It is a neurological condition characterized by a problem with basic sense of number

and quantity and difficult in retrieving note and math fact. (arithmetic combinations or

calculations) difficulty with language of math (correctly reading and understanding the text of

word problems) and visual- spatial and organizational demands of math (5)

Change the shape 6 as 9, position of numbers, 17 as 71, Poor in number sense. These

children lack mastery of basic addition, subtraction, multiplication and division combinations,

difficulty in Algebra. They are poor in geometry; subtract bigger number from smaller one, difficulty

in carrying over or borrowing sums. They may count from left to right, uses fingers for calculations

even after 8 years of age.

IV. Dyspraxia:

Dyspraxia is now not included in Dyslexia. It is considered as co-morbid condition. It is

due to small muscle weakness .These children will have poor posture, awkward clumsy

movements, poor handwriting ,immature behavior, lack of awareness of potential danger,

difficulty writing at speed, lack of fluency in reading, Poor short term memory, difficulty in

buttoning the shirt , tying the shoe lace (8).

DSM.5-Diagnostic criteria-SLD (12)

A. Any one of the following symptoms that have persisted for at least 6 months,

 1. Inaccurate or slow and effortful word reading.

 2. Difficulty in understanding the meaning of what is read

  3. Difficulties with spelling (e.g. may add, omit or substitute letters)

 4. Difficulties with written expression (e.g. makes multiple grammatical or punctuation

errors within sentences

 5. Difficulties in mastering number sense (Math)

 6. Difficulties with mathematical reasoning

B. Academic performance - Two grade low for the age

C. Onset before 7 years

D. Rule out other causes

Psychological effects of learning Disability in a Child:

School refusal, School failure, Drop out, Depression, Anxiety, Suicidal attempts,

Intolerance and Anger, run away, lack of self confidence, emotional instability, loss of self-

esteem, inferiority complex and poor socialization(2,6,10). Early identification and early

intervention by the way of remedial measures these psychological effects can be prevented.

Co- Morbid conditions with dyslexia:

Attention deficit hyperactivity disorder (ADHD), conduct disorders - oppositional defiant

disorder, anxiety disorders, depression, tic disorders and Tourette’s syndrome.

Early pointers for learning disability :

Though the confirmation of diagnosis of dyslexia can be done at 7 years. We can pick
up children by early warning signs as early as 3 years and we can follow up these children till 7
years to confirm the diagnosis of dyslexia.
1. Speech Delay
2. Missing of the crawling stage
3. Difficulty in buttoning the shirt
 4. Difficulty in tying the shoe lace
5. Difficulty with rhymes
6. Difficulty with puzzle
Though we are not confirming diagnosis of dyslexia, early intervention can be started at
3 years by phonics method of teaching from 3 years onwards, so that, we can reduce the
severity of dyslexia.

Assessment:

SLD SQ SLD Screening Questionnaire

Tamil Nadu Dyslexia Check List TnDC

If a 8year old child, in 3rd Std not able to read a paragraph from 1st std book , Academic level 2
grade less for age, it is Dyslexia .Same for Writing and Math

IQ Assessment and NIMHANS assessment

If IQ is 90-140 Dyslexia.70 – 90= Slow Learner,.>70 Intellectual Disability.

Principles of management (13)

1. Remedial education – Special educator – Educational assessment, IEP

2. Occupational therapy – e.g. Handwriting skills

3. Speech and language pathologist intervention

4. Counseling and guidance to family – psychologist/counselor

5. Treatment of associated problems – General pediatricians, developmental pediatricians,

psychiatrist

6. Career counseling – school along with parents

Remedial Teaching ( 2,6,16,17,18)

When a child is not able to understand in a way we are teaching, we will change the

way of teaching so that the child will understand. It is costly and not affordable by all

parents .Remedial teaching 2-3 hrs a day for 3 days a week for at least for 6 months is

advocated. After academic assessment they formulate individual education plan. A teacher

can handle only 2 -3 children at a time Due to high plasticity of the central Nervous system in

early years Remedial education began early when the child is in Primary School (5)
If ADHD is associated, we need to treat it first before starting Remedial Teaching

We need to send the Child for Remedial Teaching.

We need to treat the cause for other conditions

Why we need to identify dyslexic children:

1.Burden of learning disability is very high – 10% of students

2.Its only tip of the iceberg
3.Identifying at the age 7 will be ideal for better results
4.In spite of good IQ (100 to 140), they are failing in the class
5.Remedial teaching works well
6.Children’s are suffering internally due to pressure from parents & schools
7.LD children are hurt by teachers, parents, friends in spite of the fact they are not at
fault
8. Hidden tragedy
9. Unable to cope up with the educational pressure, parental pressure lead to many
psychological problems
10. Comprehensive treatment with multi-disciplinary approach can be done under one
roof
Points to Remember

 Dyslexic children read slowly word by word, hate reading, have poor hand writing,

make grammar and spelling mistakes, with reversal tendency and difficulty with

math

 Their IQ is normal or above normal and have multiple intelligence.

 Remedial teaching is the main mode of management of these children.

 No drug is needed, unless associated with co morbid condition like ADHD.

Conclusion- Vision 2020

To identify all children with Learning Disability, Dyslexia in our Nation before the end of the year
2020,and to provide free Remedial measures with the help of government as it is included in
the disability act

We as Doctors , need to identify the cause for Poor Scholastic Performance particularly the
children with Dyslexia by simple Screening as the incidence is very high 5-10%, Remedial
Teaching works well, Government is giving lot of concessions, and as on now Government is
ready to provide free Remedial Teaching as LD is included in the Disability Act 2017.