Learning disorders, and the n

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

2. 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. Specific Reading Disorder (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.
2 | Bivin,J.B (2010). Nursing Care Of Children With Learning Disorders, Dept. Of Psychiatric Nursing, NIMHANS

3. • 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. Specific Spelling Disorder
3.1. Clinical features
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
3 | Bivin,J.B (2010). Nursing Care Of Children With Learning Disorders, Dept. Of Psychiatric Nursing, NIMHANS

4. 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. 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).
4 | Bivin,J.B (2010). Nursing Care Of Children With Learning Disorders, Dept. Of Psychiatric Nursing, NIMHANS

5. 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.
5. Specific Disorders of Arithmetical Skills
5.1. Clinical features
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.
6. Mixed disorders 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
5 | Bivin,J.B (2010). Nursing Care Of Children With Learning Disorders, Dept. Of Psychiatric Nursing, NIMHANS

6. 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
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.
8. 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.
9. References
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Harris, (1995), Developmental Neuropsychiatry-Assessment, Diagnosis and Treatment of Developmental Disorders,
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Michael G. Gelder Juan J. Lopez-Ibor, Nancy Andreasen & Jaun J. Lopez-Idor(Eds.)(2003), New Oxford Textbook of
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Psychiatry, 4 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
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Sciences/ Clinical Psychiatry, 10 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-
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6 | Bivin,J.B (2010). Nursing Care Of Children With Learning Disorders, Dept. Of Psychiatric Nursing, NIMHANS