Learning Disabilities in

Children: Assesement and

Management

Dr Izan Hairani Binti Ishak

Family Medicine Specialist
Bukit Kuda Health Clinic,
Klang, Selangor 21 JAN 2020
 OUTLINE
• Introduction OF LD and ID
• Assessment
• LINUS
• Management
• Role of FMS/MO
• Conclusion
• child struggle with school?
• he or she dread reading out loud writing an
essay, or tackling a math problem?
• While every kid has trouble with
homework from time to time
• if a certain area of learning is consistently
problematic
>>>> it might indicate a learning disorder.
 WHICH ONE?
• LEARNING DISABILITY?
• LEARNING DISORDER?
• INTELLECTUAL DISABILITY?
• LEARNING DIFFICULTIES?
• MENTAL RETARDATION?
• SLOW LEARNER?
 What is a learning disability?
Having trouble:
Processing information
Organizing information
Applying information
 What Are
Learning Disabilities?

Learning disabilities are problems that affect the brain's

ability to receive, process, analyze, or store
information.

These problems can make it difficult for a child to learn

as quickly as someone who isn't affected by learning
disabilities.
 HISTORY….

• In 1980, 3rd edition DSM III first addressed

the issue of problems with learning –
Academic Skills Disorder.
• 1994, DSM IV changed to Learning
Disorder.
• 2013, the term of Learning Disorder is
used in DSM V
 Types of learning disorder

DSM IV ICD 10
 Developmental speech  Specific Reading d/o
and language disorders  Specific Spelling d/o
 Academic skills  Specific d/o of
disorders arithmetical skills
 Others ( incl.  Mixed d/o of
coordination disorders ) scholastic skills
Each have more specific
disorders
 COMMON TYPES OF LEARNING DISABILITIES IN CHILDREN
Difficulty reading Problems reading, writing,
Dyslexia
spelling, speaking
Difficulty with math Problems doing math
problems, grasping maths
Dyscalculia
concepts, understanding time,
using money
Dysgraphia Difficulty with writing Problems with handwriting,
spelling, organizing ideas

Dyspraxia (Sensory Difficulty with fine motor skills Problems with hand–eye
Integration Disorder) coordination, balance, manual
dexterity
Dysphasia/Aphasia Difficulty with language Problems understanding
spoken language, poor reading
comprehension
Auditory Processing Difficulty hearing differences Problems with reading,
Disorder between sounds comprehension, language

Visual Processing Difficulty interpreting visual Problems with reading, math,

Disorder information maps, charts, symbols, pictures
Based on
DSM V
ASD ADHD Specific
learning
Communication disorder
disorder

Neuro-
Intellectual Motor
disability developmental Disorder
disorder
 DSM V
• The American Paediatrics Association defines
specific learning disorder as reading, written
expression or mathematics skills that are
substantially lower than expected for the
individual’s age, measured intelligence and age
appropriate education level or when achievement
falls below a set standard.
DSM 5 APA 2013
 2 major changes

Category of SLD with specifiers to

characterize the specific manifestations of
learning difficulties at the time of assessment in
DSM 5 three major academic domain
 Reading Writing Mathematics

SLD
Elimination of the IQ-achievement
discrepancy requirement and its replacement
with 4 criteria (A-D), all of which must be
met
 Refers to the key characteristics of
SLD

Criterio – at least one of six symptoms

nA of learning difficulties
– persisted for at least 6
months
– despite the provision of extra
help or targeted instruction
Inaccurate or slow and effortful reading

Difficulty understanding the meaning

of what is read

Difficulties with written expression

Difficulties with spelling

Difficulties with mathematical

reasoning

Difficulties mastering numbers sense,

numbers facts or calculation
INACCURATE OR SLOW AND
EFFORTFUL READING
Who want to read
Difficulties
with
written
expression
 Difficulties mastering numbers
sense, numbers facts or calculation
 NUMBER
FACTS OR
CALCULATIO
N
 refers to measurement of those
characteristics

• below those expected for age and

• cause impairment in academic,
Criterion occupational, or everyday
B activities,
• confirmed by individually
administered standardized
achievement measures and
comprehensive clinical
assessment.
 refers to age at onset of
problems
Criterion
C • during the school-age years
• although may not fully
manifest until young
adulthood in some
individuals
 specifies which

• disorders (Intellectual Disabilities,

uncorrected auditory or visual
acuity problems, other mental or
Criterion neurological disorders) or
D • adverse conditions (psychosocial
adversity, lack of proficiency in the
language of instruction, inadequate
instruction)
• must be ruled out before a
diagnosis of SLD can be
confirmed.
MILD Some difficulties learning skills in one or two academic
domains
but of mild enough severity that the individual may be able to
compensate or function well
when provided with appropriate accommodations or support
services, especially during the school years.
MODERATE Marked difficulties learning skills in one or more academic domains
individual is unlikely to become proficient without some intervals
of intensive and specialized teaching during the school years.
Some accommodations or supportive services at least part of
the day at school, in the workplace, or at home may be needed
to complete activities accurately and efficiently.

SEVERE Severe difficulties learning skills, affecting several academic

domains
so that the individual is unlikely to learn these skills
without ongoing intensive individualized and
specialized teaching for most of the school years.
Even with an array of appropriate accommodations or services at
home, at school, or in the workplace, the individual may not be able
to complete all activities efficiently.
INTELLECTUAL DISABILITY
INTRODUCTION ID
The following :
Deficits in
adaptive
functioning

three
criteria
must be Onset :
Deficits in met developmental
period.
intellectual
functions
 A. Deficits in intellectual
functions
– reasoning
– problem-solving,
– planning,
– abstract thinking,
– judgment,
– academic learning and
– learning from experience,
– and practical understanding
– confirmed by both clinical assessment and
individualized, standardized intelligence
testing.
 B. Deficits in adaptive
functioning
• failure to meet developmental and sociocultural
standards
• for personal independence and social
responsibility.
• Without ongoing support, the adaptive deficits limit
functioning in one or more activities of daily life, -
such as communication,
• - social participation,
- and independent living,
- and across multiple environments, such as home,
school work, and recreation.
Adaptive Functioning
 SPECIFIERS:
• The use of specifiers for the neurodevelopmental disorder
diagnoses enriches the clinical description of the
individual’s clinical course and current symptomatology.

• In addition to specifiers such as age of onset or severity

ratings, the neurodevelopmental disorders may include
the specifier “associated with a medical (e g seizure
associated with a medical (e.g., seizure disorder) or
genetic condition (e.g., trisomy 21) or environmental
factor ( g, g ) e.g., low birth weight).”
 SPECIFIERS
• SEVERITY LEVELS FOR
INTELLECTUAL DISABILITY:
– Mild
– Moderate
– Severe
– Profound
 Prevalence of LD
• Hidden disability, affect 1 in 5
• Male > Female ; often quoted 5 to 1 but actual
ratio 2 to 1.
• Boys recognised more because more likely show
difficult behaviour and with discipline problems
• Lifelong condition – school, work, games, daily
routine, family life, friendships
• 25% of LD, has co-morbid condition: Attention
Deficit/Hyperactive Disorder-AD/HD
 Suspected Etiologies Of
Neurodevelopmental Disorder
 poorly understood, no real cause
 genetic causes gene defects are often unknown
 pre- or postnatal insults
 hypoxia,
 alcohol or toxin exposure,
 nutritional deficiencies,
 infection,
 trauma,
 metabolic changes.
 Hereditary – often run in family
 COMPLAINTS FROM
PARENTS/ TEACHERS
• Malas
• Tak bagi tumpuan
• Susah nak faham
• Tak duduk diam
• Lembam
• Tak minat belajar
• Suka kacau kawan
 Case study 1
• 10 y.o Malay boy
- brought by mother as she worried of her
son’s performance at school.
- under kelas pemulihan since std 1.
- last class for std 4.
- 19/27 in his class n 204/212
- mum hired home tuition.
- tutor complained difficult to understand
and lack of focus.
• Feedback from the teacher;
– Already able to read n write but very minimal
– Easily distracted at school and less focus
– Difficult to understand academic task
– Interested in ‘pendidikan seni” and ‘reka
bentuk’
– Able to socialise well and mix with friends.
• No Past Medical history
• No delay in developmental history
 Case study 2
• 7 y.o girl,
– Was advised to see a doctor during orientation
week
– Teacher noted she did not follow commands,
has very minimal words, repetitive same words
eg ‘sakit’ ‘opah’.
– Difficult to understand simple command
– Like to watch her favourite cartoon only
– Taken care by grandmum before
• Still not toilet train
• Antenatal hx uneventful, FTSVD
• No hx of admission for jaundice.
• Hx of delayed speech but no intervention
• Unable to copy the shapes
• Scribble only
• Poor eye contact
• Didn’t respond to call
 Case 3
• 9 y.o Chinese boy
– referred after LINUS assessment
– Came w mum, youngest, sister 12 y.o
– Mum noticed he became quite and has no
interest in learning after she had problem with
the husband.
– Father is heavy drinker and verbally abusive
when he drunk.
– Mother is working and come back home late
 What should we do?
• Clerk and refer to Paeds? Developmental
paeds? CDC?
• Refer to Child Psychiatrist?
• Refer to Psychologist? Child
psychologist? Clinical Psychologist?
Educational Psychologist
• Just wait and see next appt???
• Appt for CBR?
 Sources of cases with LD?
• Walk-in cases
• Opportunistic or incidental findings
• School : referral to school team or direct
call from school teacher
• LINUS programme
 INTRODUCTION OF
LINUS
• - Implemented by MOH upon request
from BPK KPM/ MOE.
• - Objective: 100% students can read and
count in year 3.
• - Involved students will be referred for
further management since 2011.
 LINUS KIT
• Senarai semak LINUS • Bola lembut 6 inci
• Kad perbagai warna
• Copy shape • Gunting
• Goodenough Draw a • Tali tape
man test • Papan tali kasut
• Borang maklumbalas • Tali dan manik (20 biji)
status murid • Siri kad bergambar
bermasalah dalam (sequential) – 4 set
pembelajaran • 3 keping kad bercerita
• Video teknik penilaian
• Buku cerita
TOOLS IN THE LINUS KIT
PICTURE STORY-TELLING
SHOELACES
 Assessment
•Parent interview- history taking
– Includes behaviour, play history and sleep pattern.
•Teacher’s report – to evaluate individual response
to academic interventions, social and behaviour at
school .
•Direct child assessment (educational and
neurodevelopmental assessment)
•Clinical examination- ?syndromic facies
Early Warning Signs
SYMPTOMS OF LEARNING DISABILITIES
• Short attention span
• Poor memory
• Difficult following directions
• Inability to discriminate between/among
letters/numerals or sounds.
• Poor reading or and writing ability
• Eye-hand coordination problems
• Difficulty with sequencing
• Disorganizations and other sensory difficulties
• Take too long to do their work? It seems to take them all
night to do what looks like a simple assignment.
• Have a hard time getting their work done in the allotted
time?
• Spend hours doing schoolwork? They often have to stay
in at recess or bring their schoolwork home in order to
get it done.
• Know they have an assignment, but cannot remember
what it is? And it's too late to call a friend and find out
what the assignment is.
• Have trouble understanding the directions?
• Work up to their abilities?
Ages 5-9 signs and symptoms of LD

• Trouble learning the connection between letters

and sounds
• Unable to blend sounds to make words
• Confuses basic words when reading
• Consistently misspells words and makes frequent
reading errors
• Trouble learning basic math concepts
• Difficulty telling time and remembering sequences
• Slow to learn new skills
 AGES 10-13 SIGNS &
SYMPTOMS LD
• Trouble learning the connection between letters
and sounds
• Unable to blend sounds to make words
• Confuses basic words when reading
• Consistently misspells words and makes frequent
reading errors
• Trouble learning basic math concepts
• Difficulty telling time and remembering sequences
• Slow to learn new skills
 Steps in evaluation
• Assess global intellectual functioning.
if global impairment -> ID
• Exclude vision and hearing impairment
• Recent/ since young?
Young- developmental
Recent – school, environment
• Any problem with engaging child/ inattention
Autism/ ADHD
 ASSESSMENT
History to be taken from parents/caretaker
during clinic visit:
BEHAVIORAL PROBLEM
• Too active – unmanageable
• Too quiet/ does not respond to name
• No interest playing with other children
• Fearful
• Self-injurious behavior
• Aggression – hitting/biting/ cruel to
animals
• Excessive tantrum
• Repetitive behavior
PLAY

• Exclusive solo
play/parallel play
• No pretend play
• No interactive play
• No free play – parents
determine the nature of
play
SCREEN TIME

• Total duration of exposure per day

inclusive of passive screen
(TV/phone/tablet)
• Content of media
• Parental supervision
SCREEN TIME
 General Condition &
Appearance

• Anthropometric measurement (Growth

chart)
• Dysmorphism
• Eye contact
• Signs of neglect (unkempt) and abuse
• Interaction with parents
 SKIN
• Neurocutaneous stigmata – eg: café au
lait, hypopigmentation etc
• Eczema
• Bruises
EARS
• Otoscope when indicated

EYES
• Ptosis
• Nystagmus
• Cataract/red reflex
• Squint •
HEART
• Pulse rate
• Any murmur

RESPIRATORY
• Respiratory rate:
• Chest deformity
• Any added sounds
ABDOMEN
• Palpable mass

SPINE
• Sacral dimple/ tuft of hair
• Any swelling

LIMBS
•Gait
DEVELOPMENTAL AND COGNITIVE
ASSESSMENT
 GESSEL FIGURES

Gesell figures are shapes that your kids can

draw and which can help you assess their
development.
• For younger children and toddlers, you
would expect that they can:
• imitates scribbling by 15 months
• scribbles spontaneously by 18 months
• imitates a stroke or line by 2 years
• differentiates between a horizontal or
vertical stroke or line by 2 1/2 years
Pre-school
School age
What do we need to do?
 Feedback

•Formulate child’s problems

•Generate a prioritised list of recommendations

•Verbal feedback

•Written report to parents and involved professionals

Management Principles
Early recognition

Evaluate for any underlying medical

condition

Appropriate referral for diagnostic

evaluation and intevention

Early intervention
 FMS/MO role:
• - coordinate a multidisciplinary team.
• - appropriate referral to Paeds, Psy,
OT/ST
• - review progress
- OKU form to be filed in
- Placement for school/ appropriate
program
- counsel parents
- request specific accommodation
• - Examples of accommodations in
education
- extended time for completing
tests
- large- print materials
- use of calculator
- laptop computers with
spellcheckers
- alternatives to multiple- choice
questions
LD is there to stay, but strategies
to work around them will make a
great difference!
 Can LD be cured/disappear?
 Doesn't disappear.
 Given the right types of educational experiences,
people have a remarkable ability to learn.
 develop their personal strengths
 The brain's flexibility to learn new skills is
greatest in young children and may diminish
somewhat after puberty.
 Early intervention is so VITAL.
 we retain the ability to learn throughout our lives.
 Penempatan sekolah
- Prasekolah Biasa (Inklusif)- belajar di bersama murid-murid prasekolah
normal/biasa
- Prasekolah khas – program pendidikan pra sekolah khusus untuk murid-
murid berkeperluan khas
- Kelas biasa (inklusif)- program pendidikan murid-murid berkeperluan
khas bersama murid-murid normal/biasa
- Program pendidikan khas integrasi- program di kelas khas bagi murid-
murid berkeperluan khas di sekolah biasa
- Sekolah Pendidikan Khas- sekolah yang menyediakan pendidikan
khusus bagi murid berkeperluan khas
- Kelas Pemulihan- program di kelas khas di sekolah harian biasa dan
sekolah khas bagi murid-murid yang bermasalah dalam menguasai
kemahiran literasi dan numerasi
- Pusat Pemulihan Komuniti (PDK) – program di beri kepada OKU yang
memerlukan pemulihan awal serta latihan asas dari segi pergerakan,
pertuturan dan kemahiran dalam aktiviti kehidupan harian.
 Conclusion
Early identification
Evaluation and assessment by trained
professionals
Special education
Tutors, speech language pathologist,
occupational therapist, psychologist
LD is there to stay, but strategies
to work around them will make a
great difference!
THANK YOU FOR YOUR
ATTENTION

019 3863989
izanhairanishak@gmail.com