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Clinical and Academic Profile of Children with Specific Learning Disorder‑mixed

Type: An Indian Study

Article · April 2018

DOI: 10.4103/jmhhb.jmhhb_18_17

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Original Article

Clinical and Academic Profile of Children with Specific Learning

Disorder‑mixed Type: An Indian Study
Anamika Sahu, Rachna Bhargava, Rajesh Sagar, Manju Mehta1
Department of Psychiatry, All India Institute of Medical Sciences, 1Department of Clinical Psychology, Holy Family Hospital, New Delhi, India

Abstract
Background: Specific learning disorder (SLD) in the past decade has gained recognition as a disabling condition among children by parents
and teachers in India. However, there are still gaps in knowledge about its clinical presentation and understanding. Therefore, the present study
was planned to evaluate the clinical and academic profile of children with SLD. Methods: The sample comprised 30 children with their age
range between 7 and 12 years with a diagnosis of SLD‑mixed type. All children were assessed through specifically designed structured pro forma
for clinical details (i.e., nature of birth, developmental milestones, and comorbidities) and academic history (i.e., history of failure, promoted
in next class, repetition in the class, school change, etc.) and SLD‑comprehensive battery. Results: The mean age of the participants was
9.6 years (standard deviation [SD] = 1.5). 76.7% of participants were male and their mean years of education was 4.7 (SD = 1.5). Thirty percent
of children had a history of delayed developmental milestones in terms of speech (16.7%), walking (6.7%) and in speech and walking (6.7%),
23% of children had comorbid conditions of attention‑deficit/hyperactivity disorder/attention‑deficit disorder. Thirty percent of children repeated
classes in their academic career. Conclusions: A significant number of children had delayed milestones and other problems. Moreover, it is
important to understand the clinical and academic profile in the cultural context so that early identification and intervention can be planned.

Keywords: Clinical and academic profile, India, specific learning disorder

Introduction with SLD experience low self‑esteem, lack of confidence, low

Specific learning disorder  (SLD) affects specific abilities in
children with an otherwise normal academic development. SLD
is defined as a heterogeneous group of neurobehavioral disorders
that clinically manifested by significant unexpected, specific
and persistent difficulties in the acquisition and use of efficient
reading, writing, or mathematical abilities. It generally occurs
despite intact senses, normal intelligence, adequate motivation,
and sociocultural opportunities.[1] Worldwide, the prevalence
of SLD has been estimated to be around 5%–15%,[2] whereas
in the Indian context, it affects approximately 0.38%–15.2%
children.[3] Prevalence studies from India have found the rate
of dyslexia as 3%–4%, dyscalculia as 3%–6% and learning
disability in general as 3%–7.5%.[3] However, it has been
documented that majority of the cases have mixed type of
errors on SLD battery and have problems in all academic area,
i.e., learning difficulty in reading, writing, and arithmetic also.[4,5]
Furthermore, comorbidity has also been documented with
SLD.[6,7] Due to poor academic performance, many children
expectations for themselves, and poor peer relationship.[8] In
addition, SLD (with or without any comorbidity) is known to
disturb the educational achievement.[9] Thus, early recognition
and intervention for SLD are required to improve learning and
to prevent emotional and adjustment issues.
Of late, awareness regarding SLD in India has increased,
especially among school authorities. However, parents still
have insufficient knowledge about SLD and its remediation.[10]
This area is under‑researched, under‑detected, and hence
undertreated in India. Published literature in Indian context
remains sparse as culture issues such as multilingualism,
poverty, teacher‑student ratio makes accurate assessment
difficult. For any effective remedial training program, it is
Address for correspondence: Ms. Anamika Sahu,
Room No: 4089, Department of Psychiatry, All India Institute of
Medical Sciences, New Delhi ‑ 110 029, India.
E‑mail: cpanamika159@gmail.com

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DOI: How to cite this article: Sahu A, Bhargava R, Sagar R, Mehta M. Clinical
10.4103/jmhhb.jmhhb_18_17 and academic profile of children with specific learning disorder-mixed type:
An Indian study. J Mental Health Hum Behav 2017;22:104-9.

104 © 2017 Journal of Mental Health and Human Behaviour | Published by Wolters Kluwer - Medknow
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Sahu, et al.: Clinical and academic profile of children with SLD‑mixed type

important to have an in‑depth understanding of clinical and needs 1–1½ h per subject. Cutoff for each scales are provided
academic issues among SLD children. However, only limited with good reliability and validity.
studies have focused on the clinical and academic profile of
these children and findings are not conclusive.[9,11] Therefore, Procedure
this study was planned to examine the clinical and academic Participants meeting the International Classification of
profile of children with SLD. Diseases 10 th  Revision diagnosis of SLD, fulfilling the
inclusion criteria were recruited for the study. Children with
SLD and their parents were informed about the nature and
Methods purpose of the study. Written informed assent/consent was
Sample obtained from the child and caregivers/parents. Parents were
A cross‑sectional sample of thirty students in the age range interviewed to record the clinical and academic profile of their
of 7–12 years were drawn from the outpatient department of child and test of SLD administered.
psychiatric, All India Institute of Medical Sciences, New Delhi,
India. In our clinical observation, maximum cases coming to Analysis
the outpatient department of psychiatric had mixed type SLD The data were analyzed using Statistical Package for Social
were in the age range of 7–12 years. All children diagnosed Sciences software, Version 21.0 (SPSS, Chicago, IL, USA).
as cases of SLD by consultant psychiatrists were recruited Descriptive statistics were applied to examine demographic,
in the study. Further, they were assessed on SLD battery to clinical, and academic variables. It included frequency,
determine the type of learning problem in all academic areas, percentage, means, and standard deviations.
i.e., reading, writing, and arithmetic. The organic conditions
like major neurological or medical disorders, impairment in Results
hearing, vision, or speech due to which learning difficulties
Demographic characteristics of the children with SLD
could occur were excluded from the study. Parents who were
are presented in Table  1. As can be seen, the mean age of
willing to participate were only included in the study.
participants were 9.6 (standard deviation [SD] = 1.5) years.
Ethical approval to conduct the study was obtained from The classes ranged from first to the seventh standard. Mean
the Institutional Ethics Committee and written informed years of education was 4.7 (SD = 1.5). Sample was primarily
consent/assent was obtained from parent/child with SLD. male  (76.7%), whereas females constituted 23.3%  (n  =  7).
Nearly 93.3% of the participants were Hindu. The equal
Assessments
proportion was represented in terms of family structure; 50%
Following tools were used were nuclear and 50% were from joint families. The majority
Sociodemographic profile sheets
This data sheet was developed for the present study by authors
to obtain sociodemographic details of the participants that Table 1: Sociodemographic characteristics of children
include age, education, gender, family type of child, etc. with specific learning disorder (n=30)
Kuppuswamy’s Socioeconomy Status Scale Variables Children with SLD (n=30)
This is developed by Kuppuswamy. 2014 revision of this
[12] Age (year)≠ 9.6 (1.5)
scale was used in present study. It takes into account education, Education (year)≠ 4.7 (1.5)
occupation, and income of the family to categorize families Gender†
Male 23 (76.7)
into upper, middle, and low socioeconomic status (SES).
Female 7 (23.3)
Clinical profile sheet Religion†
All children were assessed on a specifically designed structured Hindu 28 (93.3)
pro forma to determine the nature of birth, developmental Non‑Hindu (Sikh and Christian) 2 (6.7)
milestones, comorbidities, etc. Family type†
Nuclear 15 (50)
Academic performance profile Joint 15 (50)
Each child’s academic problems as described by the parents Socioeconomic status†
and by the teachers or counselor’s referral letter were Upper 4 (13.3)
documented. Academic history included school type, medium, Upper middle 23 (76.7)
board, regularity in attending classes in school, history of Lower middle 3 (10)
failure, promoted in next class, repetition in the class, school Domicile†
change, etc. Urban 30 (100)
Location†
Specific learning disorder‑comprehensive battery Delhi 24 (80)
It has been developed by Mehta and Sagar.[13] It includes Bender NCR 6 (20)
visuomotor Gestalt test, reading, expression both verbal and ≠
Mean (SD), †n (%). NCR: National Capital Region, SLD: Specific learning
written, comprehension, arithmetic, etc. Test administration disorder, SD: Standard deviation

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Sahu, et al.: Clinical and academic profile of children with SLD‑mixed type

of the participants belonged to the upper middle socioeconomic Secondary Education board. All children were regular to
strata  (76.7%) followed by upper SES  (13.3%) and lower their school classes  (mean  ±  SD  =  90  ±  9.1). Although the
middle class (10%). All the participants came from an urban participants had no history of failure, however, 13% of them
background (100%). Of them, 80% of the sample was residing reported being promoted to next primary class due to their
in Delhi and remaining 20% were from National Capital poor academic performance. Due to slow or poor learning and
Region (adjoining area). poor comprehension, nine children (30%) had repeated classes
in their academic career. Out of nine, eight children were
Clinical profile repeating once, and 1 (3.3%) repeated more than two times.
Table 2 shows the clinical profile of children with SLD. Of all However, there was no history of school change. Participants
the participants, 10% (n = 3) of children were born of cesarean were receiving help from teachers and parents (30%), tutors and
section and rest of the children had normal vaginal delivery. parents (36.7%) and parents only (33.3%). Most of the cases
Nearly 6.7% of children had delayed cry (n = 2). In terms of were referred by their school teachers or counselor (53.3%).
delayed milestones, approximately 30% of the participants Some parents were referred or suggested for psychological
had delayed milestones in domain of speech (16.7%), walking consultation by their doctors (10%) and friends/relatives (20%)
(6.7%) and 6.7% had delay in both, i.e., speech and walking. and 5 parents  (16.7) were approached for diagnosis and
Further, it was seen that one child had history of asthma and treatment by themselves.
remain participants did not have any major illness. 23% of
children exhibited signs of attention deficit hyperactivity Errors on reading, spelling and writing
disorder or attention-deficit disorder (ADHD or ADD) and Errors made by children on reading  (Hindi and English)
20% of them were on medication to maintain their attention and writing (Hindi and English) subtests of the
for a long time and to mellow down their hyperactivity. All SLD‑comprehensive battery are displayed in Figures  1‑4.
children had average level of intelligence. Participant’s performance on spelling and mathematics has
been shown in Tables 4 and 5.
Academic details
Table 3 shows the academic details of children with SLD. All
children started schooling between the age ranges of 2.5 and Discussion
4 years. All children were being educated in English medium. As we know children with SLD are similar as other children in
Only two children were studying from Indian Certificate of their physical and intellectual constructs. Learning problems
in academic areas are not very oblivious at early years of a
child. It displays in the form clinical (e.g., delayed milestones,
Table 2: Clinical profile of children with specific learning comorbid conditions) and academic deficits (unable to grasp
disorder (n=30) prerequisite skills or comprehends basic rules). Because of this,
Variables Children with SLD (n=30) most of the time parents and teachers and even professionals
Birth complication† deliberately ignore the signs and symptoms of SLD. They
Present 3 (10) justify child’s academic problems with his/her age, problem
Absent 27 (90) behaviors or mistakes of teachers and parents. Moreover,
Delayed cry† they are unable to distinguish learning problem or condition
Present 2 (6.7) with normal learning that leads to delay in identification and
Absent 28 (93.3) remediation. Thus, it is important to understand clinical and
Delayed milestones† academic problems of these children to fix it timely.
Speech 5 (16.7)
Very few studies from the Indian subcontinent have examined
Walking 2 (6.7)
the clinical and academic profile of children with SLD. Here,
Speech and walking 2 (6.7)
Absent 21 (70)
Any major illness† Omission
Present 1 (3.3) Substitution
Absent 29 (96.7)
English reading errors

Insertion
Psychiatric illness† Poor punctuation

ADHD 7 (23.3) Gross pronunciation

Hesitation/halty
No 23 (76.7)
Miss lines
Medication†
Asked to examiner
Yes 6 (20)
Reading word by word
Compliant for medication† Reading letter by letter
Yes 6 (20) Reluctant to read
Intelligence 0 5 10 15 20 25 30 35
Full IQ≠ 104 (8.9) Number of participants
≠
Mean (SD), †n (%). ADHD: Attention deficit hyperactivity disorder,
SLD: Specific learning disorder, SD: Standard deviation Figure 1: English reading errors

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Sahu, et al.: Clinical and academic profile of children with SLD‑mixed type

Table 3: Academic details of children with specific learning disorder (n=30)

Domain Sub domain Frequency, n (%)
School type Government 3 (10)
Private 27 (90)
Education medium English 30 (100)
Education board CBSE 28 (93.3)
ICSE 2 (6.7)
Regularity in attending school‡ 90 (9.1)
Regularity in passing class Passed 26 (86.7)
Had to be promoted once 1 (3.3)
Had to be promoted twice 2 (6.7)
Had to be promoted more than two time 1 (3.3)
Promoted in class Class 1 1 (3.3)
Class 2nd and 3rd 1 (3.3)
Class 3rd, 4th, 5th 1 (3.3)
Class 5th and 6th 1 (3.3)
Grade retention/repetition One time 8 (26.7)
≥2 time 1 (3.3)
Not applicable 21 (70)
Repeated in grade KG 2 (6.7)
Class 1 5 (16.7)
Class 3 1 (3.3)
Class 4 1 (3.3)
Not repeated 21 (70)
School changed No 30 (100)
Receiving help Teachers and parents 9 (30)
Tutors and parents 11 (36.7)
Parents only 10 (33.3)
Referred by School teacher/counselor 16 (53.3)
Doctors 3 (10)
Friends/relative 6 (20)
Self 5 (16.7)
Mean (SD). SD: Standard deviation
‡

Omission
Table 4: Performance of children with specific learning
Substitution
disorder (n=30) on spelling test
Insertion
Hindi reading errors

Spelling Mean (SD) Poor punctuation

Gross pronunciation
English Hindi
Hesitation/halty
Correct words 6 (2.3) 5.2 (2.6) Miss lines
Errors 9.0 (2.3) 9.3 (2.8) Asked to examiner
SD: Standard deviation Reading word by word
Reading letter by letter
Reluctant to read
Table 5: Performance of children with specific learning 0 5 10 15 20 25 30
disorder (n=30) on mathematic test Number of participants

Mathematics Value, mean (SD) Figure 2: Hindi reading errors

Addition
Correct response 3.57 (1.19) the study extends an understanding of the clinical and academic
Subtraction profile of children with SLD‑Mixed type. This study showed
Correct response 2.95 (1.54) that most children with SLD had developmental milestones
Multiplication
within normal range. However, more than one‑fourth of
Correct response 1.87 (1.31)
Division
children had a history of delayed developmental milestones in
Correct response 1.90 (1.32) term of walking and speech or both. In addition, approximately
SD: Standard deviation one‑fourth of children were exhibiting symptoms of ADHD.

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Sahu, et al.: Clinical and academic profile of children with SLD‑mixed type
Wrong capitalization
Omission
English writing errors
Insertion
Poor punctuation
Poor space
Neatness
Missed lines
Spelling errors
Poor letter formation
0 5 10
Number of participants
Figure 3: English writing errors
These findings are in line with previous studies where
SLD children showed delayed milestones and ADHD
symptoms.[9,11,14,15] Recently, a study has examined the clinical
and psychoeducational profile of children with SLD with
ADHD and they found delayed developmental milestones in
around 24% of the children with SLD. Reading disorder was
the most common SLD type along with ADHD.[7]
In India, there are no examinations for primary classes and
the child reaches 8th  standard without much evaluation.
This is especially true for government formal schools
where the teacher‑student ratio is quite disproportionate. In
addition, in public schools, it largely depends on parent’s
level of awareness and the thought of retaining the child
in a particular class is rare. Hence, they are promoted to
next class despite their poor performance in scholastic
areas. In this study, only one‑fourth of participants repeated
their classes in their whole academic span and more than
one‑sixth of children were promoted to their next class
with recommendation for an extra class or remedial classes.
Karande et al.[9] also found a similar pattern where 30% of
children had a history of class retention. Furthermore, these
cases were primarily referred by school teachers or counselor
for the diagnosis of SLD and further management. They also
reported that in their clinic, referral for diagnosis of SLD
was made by the school principle or the classroom teacher
or school counselor.
Furthermore, the findings of the study should be contextualized
in terms of the strengths and limitations. The strength of
the study includes assessing for the first time clinical and
academic profile of SLD‑mixed type. This finding will help
to understand the associated factors with SLD children that
should be considered at the time of diagnosis and management
of SLD children. There are few limitations of the current
study that need to be mentioned and addressed in future
studies. First, small sample size, there is a need for still larger
samples to know exact proportion of problems. Second,
lack of comparison with other disorder or controls and third,
cross‑sectional design.
108
Omission
Insertion
Hindi writing errors
Poor punctuation
Poor space
Neatness
Missed lines
Spelling errors
Poor letter formation
15 20 25 30 35 0 5 10 15 20 25 30 35
Number of participants
Figure 4: Hindi writing errors
Conclusions
This study extends our understanding of clinical and academic
details of children with SLD-mixed type. The results, definitely,
add crucial points to the existing literature. However, much
work needs to be carried out with sophisticated study design.
Moreover, the main aim should not be only to find faults with
the child but also to successfully identify strengths as well as
weaknesses and integrate them in management plan which
may then ease the process of learning.
Financial support and sponsorship
Nil.
Conflicts of interest
There are no conflicts of interest.
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Journal of Mental Health and Human Behaviour  ¦  Volume 22  ¦  Issue 2  ¦  July-December 2017 109

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