Specific learning disability An overview of current guidelines

Specific learning disability: An overview of current guidelines & Issues requiring focus Dr. Deepak Kumar Assoc Professor & Head, Department of Psychiatry Institute of Human Behavior and Allied Sciences (IHBAS)

Introduction • DSM-5 considers Specific Learning Disability (SLD) as a type of Neuro-developmental disorder that impedes the ability to learn or use specific academic skills • Most definitions suggest a significant discrepancy between what the child has actually learned(achievement) and what the child is potentially capable of learning(ability)

Introduction (contd. ) • The early signs of learning difficulties may appear in the pre-school years, but they can be reliably diagnosed after starting formal education. • SLD is understood to be cross-cultural and chronic condition that typically persists into adulthood. • SLD is a clinical diagnosis.

Common presentations of SLD • With impairment in reading: Dyslexia • With impairment in written expression: Dysgraphia • With impairment in mathematics: Dyscalculia • Mixed forms of impairments are quite common

Assessment • • Needs to be comprehensive History , Physical exam, visual acuity, hearing Behavioural Assesment Reviewing notebooks Academic Report from teachers Standardized Tools (Nimhans Battery) Important to rule out intellectual impairment

Public Learning…

Role of Provisions • Provisions formulated to help SLD children continue in regular mainstream school • Provisions function as ‘corrective lens’: distorted array of observed scores in learning back to where they ought to be • Provisions serve to "level the play field“: academic performance now commensurate with intellectual ability

Maharastra • In Maharashtra, The state board recognizes certification only from three hospitals – Lokmanya Tilak Municipal Medical College, Sion, Mumbai (Sion Hospital) and Nair Hospital; KEM Hospital, Mumbai also certifies children having SLD or from the Government Surgeon General in Mumbai.

Karnataka • In Karnataka, Candidates with SLD need to be certified as dyslexic from either NIMHANS, Bangalore, St John’s Hospital, Bangalore; All. India Institute of Speech and Hearing, Mysore; any psychiatrist working in a government hospital; any clinical psychologist with an M. Phil. Qualification and attested by a government doctor (not below the rank of a district surgeon).

Kerala • In the state of Kerala, SLD certificate with a LD assessment and IQ assessment report from a psychiatrist above rank of Asst. surgeon in any Govt. Hospital was valid. • The report needed to specify the deficit & becountersigned by the District Education Officer • The request for assessment &later submission for provisions is to be made by the school Principal.

Delhi • In Delhi, Special educators and clinical psychologists assess and provide their assessment report to the clients referred. • The children were referred to the Institute of Human Behaviour and Allied Sciences (IHBAS) • The cerificates issued by IHBAS was accepted by CBSE and University of Delhi

CBSE relaxation • Exemption from third language • Extra time (additional 01 Hour) in exam • Permission to have a writer/amanuensis

ICSE relaxation • As per ICSE, the Council may grant exemption from the study of a second language, to a candidate with special difficulty, provided the case warrants such an exemption, because of the severe nature of the learning disability of the candidate. • Such an exemption will be granted only on a recommendation sent by the head of the school and on provision of the necessary documents certified by a competent authority approved by the State/Central Government and acceptable to the Council.

Maharashtra Govt. (Applicable for all boards) • • 25% Extra time Oral Test along with the written examination for Standard I to IX. Promotion to next class on the basis of the Average Writer/ typewriter Question papers to be read out Exemption from the Second and Third Language Physiology-Hygiene and Home Science in place of Science Arithmetic – – • • Standard I to IV – errors of interchanging of computation signs and number reversal to be ignored Arithmetic of Standard V in Standard V & VI Arithmetic of Standard VI in Standard VII & VIII Arithmetic of Standard VII in Standard IX & X Use of Calculator at Class X Examination Spelling errors and incorrect sentence construction to be ignored. Errors in respect of showing directions in Geography to be ignored. Students between Standard I & IX exempted from drawing diagrams, graphs, and charts. Marks for such questions proportionately distributed to the other questions or students to be provided with supplementary questions. 20% consolidated grace marks in one or more subjects Students are permitted to write in ordinary print Exempted from having to write answers in detail during exams

Maharashtra- Secondary School Certificate (SSC) board examination 1. Extra time of 30 minutes for all written tests with spelling mistakes being overlooked, 2. Employing a writer for children with dysgraphia, 3. Exemption of a second language (Hindi or Marathi in an English medium school) and substituting it with a work experience subject, and 4. Exemption of standard X mathematics (algebra and geometry) and substituting it with lower grade of mathematics (standard VII) and another work experience subject

University of Delhi • Admission under 3 percent disability quota, for persons with dyslexia with 40 percent or more disability under Section 39 of the Persons with Disability Act, 1995 (as per High Court order)

SLD: Disability Rights – Changing Face of Disability Movement: From Charity to Empowerment – ? Physical Disability, ? ? Mental Disability – Persons with Disability Act (PWD)1995 – National Trust Act 1999 – Cut off described as 40% for the disability benefits – Lack of scientific tool to quantify the disability – Who does the certification? ? Pediatricians, Psychologists, Social workers, Psychiatrists…

Need for uniformity…. • There was a need to have a uniform system for identification, diagnosis and of certification for the whole country. • The Maharashtra State Board of Secondary and Higher Education provided a plethora of concessions while the two national boards of the country provide only a few rather general concessions.

Specific Learning Disability: IHBAS experience Institute of Human Behavior and Allied Sciences, Delhi v A premier institute of neuropsychiatry located at Delhi v Covers population from Delhi-NCT, Uttar Pradesh, Haryana, Punjab, Madhya Pradesh, Bihar, Rajasthan, and many others

Specific Learning Disability: IHBAS experience • • • Have the multidisciplinary facility for evaluation and certification Psychological Assessment Report not felt enough by the schools Delhi University’s reservation policy for SLD Role of medical board for certification Need to sectorise the disability certification process Role of NIPCCD and other mental Health professionals (private sector)

Specific Learning Disability: IHBAS experience v As no mechanism was available to quantify the degree of disability in cases of SLD- scientifically agreed upon or administratively approved. v In this scenario, the clinical grading of SLD as moderate can be considered as satisfying the need of the degree of disability being over 40% as required by the PWD Act, 1995.

Specific Learning Disability: IHBAS experience v The Disability certification is to accrue the academic benefits for the students (not the social welfare related benefits) v Till date >250 SLD related disability certificates have been issued through the medical board.

RPWD Act -2016 • Prepared by the ministry of social justice and empowerment has widened its definition of disability to give legal recognition to include those living with speech and language disability and specific learning disabilities such as dyslexia. • It is also including categories from another legislation, the National Trust Act, which caters specifically to autism, cerebral palsy and mental disabilities.

MINISTRY OF SOCIAL JUSTICE AND EMPOWERMENT [Department of Empowerment of Persons with Disabilities (Divyangjan)] NOTIFICATION New Delhi, the 4 th January, 2018 • Now, therefore, in exercise of powers conferred by Section 56 of the Rights of Persons with Disabilities Act, 2016 (49 of 2016), the Central Government hereby notifies the guidelines for the purpose of assessing the extent of following specified disabilities in a person after having considered the recommendations of the Ministry of Health and Family Welfare as provided at Annexure II, namely: - • I. Locomotor disability including cerebral palsy, leprosy cured, dwarfism, acid attack victims and muscular dystrophy; II. Blindness and low-vision; III. Deaf and hard of hearing and speech and language disability; IV. Intellectual disability and specific learning disabilities; V. Mental illness; VI. Chronic neurological conditions; VII. Haemophilia, thalassemia and sickle cell disease; and VIII. Multiple disabilities. • •

22. Specific Learning Disability (SLD): • 22. 1. Definition. -"specific learning disabilities" means a heterogeneous group of conditions wherein there is a deficit in processing language, spoken or written, that may manifest itself as a difficulty to comprehend, speak, read, write, spell, or to do mathematical calculations and includes such conditions as perceptual disabilities, dyslexia, dysgraphia, dyscalculia, dyspraxia and developmental aphasia;

22. 2. Screening • (i) The teachers of the public and private school shall carry out the screening in Class III or at eight years of age, whichever is earlier. • (ii) Every school (public and private) shall have a screening committee headed by the principal of the school. After applying the screening test, if an anomaly is detected then, the teacher should bring it to the notice of principal and screening committee of the school. The teachers shall interview the parents to assess their involvement & motivation regarding their child’s education. • If the parents are motivated and screening questionnaire suggests SLD, then child should be referred for further assessment.

22. 3. Diagnosis: • The diagnosis will require a team approach involving a pediatrician and clinical or rehabilitation psychologist. This would involve three steps: • (i) Step 1 -Assessment of paediatrician: The paediatrician will do the initial assessment. This will involve a detailed neurological examination including vision and hearing assessment. It has to be ensured that the child has normal visual acuity and hearing before proceeding to next step. • (ii) Step 2: IQ Assessment: Child/ clinical psychologist will do the IQ assessment using MISIC or WISCIII. If the IQ is determined to be >85, then step 3 will be applied. • (iii) Step 3 - SLD Assessment: This would involve application of specific psychometric tests for diagnosing SLD and giving it a severity scale.

22. 4. Diagnostic Tool • National Institute for Mental Health and Neurosciences (NIMHANS) battery shall be applied for diagnostic test for SLD.

22. 5. Medical Authority: • The Medical Superintendent or Chief Medical Officer or Civil Surgeon or any other equivalent authority as notified by the State Government shall be head the certification authority. The medical authority will comprise of: (a) The Medical Superintendent or Chief Medical Officer or Civil Surgeon or any other equivalent authority as notified by the State Government (b) Pediatrician or Pediatric Neurologist (where available) (c) Clinical or Rehabilitation Psychologist (d) Occupational therapist or Special Educator or Teacher trained for assessment of SLD.

22. 6. Validity of Certificate: • The certification will be done for children aged eight years and above only. • The child will have to undergo repeat certification at the age of 14 years and at the age of 18 years. • The certificate issued at 18 years will be valid life-long.

Lacunae in SLD certification • In the Guidelines, Psychiatrists are excluded from the medical board certifying SLD. • The NIMHANS Battery is applicable only up to the age of 12 years or grade seven (the age of certification as per the guidelines is 8, 14, and 18 years). It is a screening tool &not diagnostic. • Pediatricians/pediatric neurologists newly introduced in the certification board have expressed apprehension & lack of clinical awareness regarding behavioural aspects of Neuro-developmental disorders to the authorities in some of the states (Thomas et al 2018)

Current Situation…. • Since the introduction of the Notification, children with disabilities have been suffering long queues & running from pillar to post due to lack of pediatrician expertise in dealing with certification of neurodevelopmental disorders. • Notifications are expected to be released from Delhi Govt for district wise identified hospitals for certification of disabilities.

DALI- a screening Tool • The first standardized validated screening and assessment tool in 4 Indian Languages: Hindi, Marathi, Kannada and English • Initial testing: 4840 children in five cities – Delhi-NCR, Allahabad, Pune, Mumbai and Mysore were tested for this tool. • Currently: 28000 kids with Delhi Govt. • Screening in Hindi and English is available on cell phone.

Summary • Area of Disability Rights for persons with SLD has been in focus in recent times • Mere inclusion of SLD as a disability will not be sufficient unless there is also uniformity in provisions. • Advocacy by the stakeholders for more comprehensive disability benefits • SLD certification must include Psychiatrists in the Medical authority

Summary (contd) • Regular teachers as well special educators of children with special needs must be trained to deal with SLD. • There is also a dire need to spread awareness and disseminate information about SLD by trainers, teachers, parents and the medical fraternity especially relating to assessment, diagnosis and provisions.

Summary(contd) • The issue of quantification & use of a better more standardized tool for the assessment, with necessary modification in guidelines is imperative.