Cognition in specific learning disability
http://www.100md.com
《美国医学杂志》
Department of Pediatrics, Lokmanya Tilak Municipal Medical College and General Hospital, Sion, Mumbai, India
Abstract
Objective: To compare the cognition abilities of children with specific learning disability (SpLD) viz. dyslexia, dysgraphia and dyscalculia with those of non-impaired children. Methods : The study group consisted of 95 newly diagnosed SpLD children (aged 9-14 years) and the control group consisted of 125 non-impaired children (aged 9-14 years). An academic achievement of two years below the actual grade placement on educational assessment with a Curriculum-Based test was considered diagnostic of SpLD. A battery of 13 cognition function tests based on Guilford's Structure of Intellect Model was administered individually on each child in four areas of information viz. figural, symbolic, semantic and behavioral. Mean scores ± SD obtained in these four areas were calculated in both groups and compared using Independent Samples t-test. A P value < 0.05 was considered significant. Results : Children with SpLD had significantly lower scores (mean ± SD) in all four areas of information: maximally in the symbolic area (18.66 ± 4.83 vs. 28.30 ± 4.29, mean difference 9.64, P< 0.0001, df = 218, 95% CI 8.43-10.86), followed by semantic (18.72 ± 5.07 vs 27.36 ± 4.17, mean difference 8.64, P< 0.0001, df=218, 95% CI 7.40-9.87), figural (17.10 ± 5.24 vs 25.14 ± 3.36, mean difference 8.04, P< 0.0001, df=218, 95% CI 6.89-9.19), and behavioral (5.68 ± 2.10 vs 7.54 ± 1.46, mean difference 1.86, P< 0.0001, df = 218, 95% CI 1.39-2.33) areas. Conclusion : Cognition abilities are significantly impaired in children with SpLD.
Keywords: Cognition disorders; Dyslexia; Mainstreaming (Education); Remedial Teaching
Specific learning disabilities (SpLD) is a generic term that refers to a heterogeneous group of disorders manifested by significant unexpected, specific and persistent difficulties in the acquisition and use of efficient reading (dyslexia), writing (dysgraphia) or mathematical (dyscalculia) abilities despite conventional instruction, intact senses, normal intelligence, proper motivation and adequate socio-cultural opportunity. [1],[2],[3] The term SpLD does not include children who have learning problems which are primarily the result of visual, hearing, or motor handicaps, of subnormal intelligence, of emotional disturbance, or of socio-cultural disadvantage.[4],[5] Although still a mater of debate, this exclusionary definition has been adopted by the diagnostic and statistical manual of mental disorders (DSM-IV) and the international classification of diseases (ICD-10), classification of mental and behavioral disorders.[4],[5]
SpLD are one of the most common neurobehavioral disorders in children. [1],[2],[3] They constitute an invisible handicap and are important causes of poor school performance. [1],[2],[3] They are intrinsic to the individual and are presumed to be due to central nervous system dysfunction.[6]
Dyslexia (or specific reading disability) is the most common and most carefully studied of the learning disabilities, affecting 80% of all those identified as learning-disabled.[2] The incidence of dyslexia in school children in USA ranges between 5.3- 11.8%.[7] Substantial evidence has established that dyslexic children have deficits in "phonologic awareness", which consistently distinguish them from those who are not reading-impaired.[6] According to this "phonologic-deficit hypothesis", dyslexic children have difficulty developing an awareness that words, both written and spoken, can be broken down into smaller units of sound and that; in fact, the letters constituting the printed word represent the sounds heard in the spoken word.[6]
Information on SpLD in Indian children is scanty. A recent study from South India has reported the incidence of dyscalculia to range between 5.5- 6% in primary school children.[8]
Cognition is an intellectual or mental process of acquiring knowledge and it plays an important role in learning. Cognition disorders are disturbances in the mental process related to thinking, reasoning, and judgment. Studies done in USA, Canada and Italy have reported that children with SpLD have cognition disorders. [9],[10],[11],[12]
Since 1996, the authors have been running a Learning Disability clinic which is the sole Certification Centre recognized by the State Ministry of Education, Government of Maharashtra. The present study was conducted to assess cognition abilities in children with SpLD, and to compare their cognition abilities with those of non-impaired children. This study has been conducted considering that there is no knowledge of such a study being reported from India.
Materials and methods
Selection of Cases
This case-controlled cross-sectional study was conducted over a period of 15 months, from January 2001 to March 2002. The study group consisted of children, aged nine years and above, and in whom SpLD were newly diagnosed, i.e. they had not yet undergone remedial education. Currently, SpLD cannot be conclusively diagnosed until the child is about eight to nine years old.[2] These SpLD children were attending English medium schools in the city of Mumbai and nearby districts and had been referred to learning disability clinic by their school principals with complaints of poor academic performance.
First, audiometric and ophthalmic examinations were done to rule out hearing and visual deficits. Children in whom non-correctable hearing or visual deficits were detected did not qualify for a diagnosis of SpLD.
Each child was assessed by a multidisciplinary team comprising of Pediatrician, Counselor, Clinical Psychologist and Special Educator before the diagnosis of SpLD was confirmed.[1],[13] The Pediatrician took a detailed clinical history and did a detailed neurological examination. The Counselor took a thorough social history to rule out emotional problem that could have been primarily responsible for the child's academic underachievement. If severe emotional disturbances, or depression, or attention deficit hyperactivity disorder (ADHD) were suspected the child was also assessed by a Child Psychiatrist. Children diagnosed with severe emotional disturbances or depression were not enrolled in the study, as these children needed to be first treated for a few months for these conditions before assessment for SpLD could be done.[1]
The Clinical Psychologist conducted the standard test for determining the child's level of intelligence (i.e. intellectual potential) viz. Wechsler Intelligence Scale for Children-Revised (WISC) (Indian adaptation by MC Bhatt).[14]
Employing a locally developed Curriculum-Based test, the Special Educator (RS) conducted the educational assessment in specific areas of learning viz basic learning skills, reading comprehension, oral expression, listening comprehension, written expression, mathematical calculation and mathematical reasoning. An academic achievement of two years below the actual grade placement was considered diagnostic of SpLD.[1],[13] Curriculum-based assessment is a recommended method of assessing a child's academic achievement.[13],[15] This test is a criterion-referenced test devised by the Learning Disability clinic's Special Educator (RS) and is based on the curriculum followed in Mumbai schools.
In the clinic, since both the WISC test and the Curriculum-Based test are conducted in English, children in whom "language barrier" was suspected to be the cause of poor school performance, i.e., those who were not conversant in English as they came from non-English speaking families, could not be assessed for SpLD.
Children diagnosed with SpLD and having co-morbid conditions which are known to impair cognitive functioning viz ADHD or epilepsy being treated with antiepileptic drugs were also excluded from the study.[1]
The control group consisted of non-impaired children and was selected from a nearby English medium school. For inclusion in the control group, the classroom teacher was consulted to ensure that the child did not have a history of academic underachievement or any current schooling problems or epilepsy being treated with antiepileptic drugs.
Cognition Function Tests
All children enlisted in the study were in good health. Informed consent was taken from their parents to undergo the cognition function tests (CFTs). One of the authors (SS) administered a battery of 13 CFTs on each child individually. These psychometric tests have been devised by Jnana Prabodhini's Institute of Psychology, Pune, with support of the National Council of Educational Research and Training (NCERT), New Delhi, and are based on the Guilford's Structure of Intellect (SOI) Model.[16],[17] These tests have been standardized after administering them to over 300 school children.[16] The tests' kit is available from: Jnana Prabodhini, 510 Sadashiv Peth, Pune 411 030, India
These 13 CFTs assessed cognition in four areas of information table1: figural (code numbers 112, 113, 114), symbolic (code numbers 121, 122, 125), semantic (code numbers 131, 133, 134, 135, 136), and behavioral (code numbers 141, 146). Each of these 13 CFTs comprised of sub-tests which tested the same specific cognitive function. This ensured that the test scores obtained by the child were valid and not due to chance.[16]
Each test had two sample questions. As recommended, each child was explained about these two examples before he / she undertook the test.[16] Generally, the sequence for the CFTs was: first, tests of figural information, then symbolic, semantic and finally behavioral. However, the child was allowed to alter this sequence if so desired, as this in no way influences the scores.[16] As recommended: while undergoing these 13 tests the child was not allowed to: (i) answer another test without having completed the one being administered, or (ii) change the answer of any previously administered test. There were no time constraints for completing the CFTs, and a child had the freedom to leave a test without answering all its sub-tests if he / she found it difficult. It took about 60 to 90 minutes for a child to complete the CFTs.
Data Analysis
Each child's CFTs scores were calculated in these four areas of information. The maximum marks a child could score were 116. The data obtained was analyzed using the Statistical Package for the Social Sciences, version 7.5 for Windows (SPSS Ltd., Chicago, Illinois, USA). Mean scores ± SD obtained in these four areas of information were calculated in both groups of children. Results obtained were compared using Independent Samples t-test. A P value< 0.05 was considered significant. Two-tailed significance was obtained in all cases.
Results
A total of 95 children with SpLD were included in the present study. Their age ranged from 9-14 years table2, with mean age 12.32 years (SD, 1.48). There was a male preponderance in the study group, with a male: female ratio of 3.8: 1. A diagnosis of dyslexia was made in 94/95 (98.9%), dysgraphia in 92/95 (96.8%), and dyscalculia in 89/95 (93.7%). However, most of the children in the study group viz 86/95 (90.5%) had all three types of SpLD present concomitantly.
In the control group, 125 non-impaired children were included. Their age ranged from 9-14 years table2, with mean age 11.83 years (SD, 1.73). Their male: female ratio was 1.1:1.
Children with SpLD had significantly lower scores in each of the 13 CFTs table3a. When the overall CFTs scores in the areas of information were compared in the two groups table3b, children with SpLD had significantly lower scores in all four areas of information ( P < 0.0001). However, their cognition was impaired maximally in the symbolic area (mean difference in scores was 9.64), followed by semantic, figural and behavioral areas of information table3b.
Discussion
Employing psychometric tests based on the Guilford's SOI Model, the present study has documented that Indian children with SpLD have significantly impaired cognition abilities. Also, the present study has identified that their cognition is impaired maximally in the symbolic area of information, followed in descending order by semantic, figural and behavioral areas of information.
It is well known that children with SpLD exhibit a severe discrepancy between their intellectual potential and academic achievement. [1],[2],[3] SpLD is not just a school disability, it is a life-time disability. The same dysfunctions that interfere with normal learning processes may also have impact on self-image, peer and family relationships, and social interactions. [1],[2],[3] However, if SpLD is diagnosed and treated early, the child has the potential for a reasonably successful future. The cornerstone of treatment of SpLD is remedial education. [1],[2],[3]Hence, early referral to a Special Educator for remedial education when the child is in primary school is crucial. [1],[2],[3]
Using specific teaching strategies and teaching materials, the Special Educator formulates an Individual Education Program (IEP) to reduce, eliminate or preclude the child's deficiencies in specific learning areas such as reading, writing and mathematics identified during the child's educational assessment. The child has to undergo these "remedial" sessions twice or thrice weekly, during which he/she undergoes systematic and highly structured training exercises to learn that words can be segmented into smaller units of sound ("phoneme awareness"), and that these sounds are linked with specific letters and letter patterns ("phonics").[2],[18] The child also requires practice in reading stories, both to apply newly acquired decoding skills to reading words in context and to experience reading for meaning.[2] Although remedial education concentrates almost exclusively on trying to impart academic skills by "teaching around" disabilities, it is known to alleviate underlying cognitive problems and help achieve academic competence.[12],[18] However, remedial education is expensive (one session costs ~Rs.250/-) and the child needs to undergo it for a few years (two to five) till he / she learns to largely overcome the disability.[2],[18]
What is the utility of the present study First, it is postulated that these CFTs can be used by Special Educators to objectively assess the progress being made by a child undergoing remedial education. The authors suggest that every child should perform on these CFTs at the time SpLD is diagnosed, i.e. before remedial education is begun. After the child has undergone remedial education for at least a year, which is usually the average minimum time required for it to start showing benefit, the child should again perform on these CFTs. The authors believed that the child's scores on the follow-up CFTs would then be higher. This would be an objective assessment of the effectiveness of remedial education which would reassure the child's parents of the utility of this rather expensive therapy. The improved scores would convince them to continue their child's remedial education, and this would enable the child continue education in a regular mainstream school. The authors follow-up research on the same subjects is examining this postulation. Second, we suggest that in addition to the regular remedial education sessions that address phonological coding, children with SpLD should also simultaneously undergo strategic interventions to alleviate their impaired cognition, especially in the symbolic and semantic areas of information. In recent years in Canada, USA and UK "cognitive remedial therapy", given along with the regular remediation education, is being increasingly recognized as an effective method to optimize the rehabilitation of children with SpLD. [19],[20],[21]
Two potential limitations of the present study need to be mentioned. First, the two groups could not be gender-matched table2. It is well known that more boys than girls are referred for detection of SpLD, and the authors could not overcome this limitation.[7] Second, the present study was restricted to measuring "cognition", which is the first of the five intellectual operations described by Guilford to describe intelligence.[17] The other operations, viz., memory (retaining and recalling the contents of thought), convergent production (producing a single best solution to a problem), divergent production (producing a variety of ideas or solutions to a problem) and evaluation (deciding whether the intellectual contents are positive or negative, good or bad) have not been evaluated by the authors. However, there is no reason to believe that this adversely affects the utility of the present results, as Guilford has clearly stated that each of the five operations function independently.[17]
The authors cannot compare the present study with previous work because there is no such study. A detailed Medline / PubMed search did not find any such study, in India or elsewhere, which has analyzed cognition in children with SpLD using tests based on the Guilford's SOI Model.
In summary, the present study documents that Indian children with SpLD have significantly impaired cognition abilities. Additional studies are required in various parts of the country to determine the generalization of these results.
Acknowledgements
The authors thank the Dean, Dr. M.E. Yeolekar for granting permission to publish this study. Thanks are due to the Principal, Jnana Prabodhini's Institute of Psychology, Pune for granting us permission to use their Cognition Function Tests for the present study; Rajiv Gandhi Foundation, New Delhi for its grant for Learning Disability Clinic; the Principal, V.N. Sule Vidyalaya, Mumbai for allowing to enlist children who comprised the control group; and Dr. D.P. Singh, Reader, Department of Research Methodology, Tata Institute of Social Sciences, Mumbai for his help in the statistical analysis of the data. Lastly, the authors thank the children who participated in this research project.
Contributors
SuK initiated and designed the study, directed the data analysis and wrote the manuscript; he will act as the guarantor of the paper. SS conducted the Cognition Function Tests, performed the literature review, and edited the manuscript. MK helped in designing the study, discussed the core ideas and analysis, and edited the manuscript. SaK helped in literature review and data analysis, discussed the core ideas, and edited the manuscript. RS helped in designing the study, conducted the educational testing, discussed the core ideas and analysis, and edited the manuscript.
Funding: None.
Competing Interests: None.
This paper is based on the dissertation submitted to University of Mumbai for MD (Pediatrics) degree examination held in January 2003. Sunil Karande was the postgraduate dissertation guide and Sulaxna Sawant was the postgraduate student.
This paper was presented as a Poster Presentation at the "8th Asian & Oceanian Congress of Child Neurology", organized by the Asian & Oceanian Child Neurology Association, Indian Academy of Pediatrics- Child Neurology Chapter and Association of Child Neurology, held at New Delhi, India, October 7-10, 2004.
References
1. Shapiro BK, Gallico RP. Learning disabilities. Pediatr Clin North Am 1993; 40: 491-505.
2. Shaywitz SE. Dyslexia. N Engl J Med 1998; 338: 307-312.
3. Shalev RS, Manor O, Auerbach J, Gross-Tsur V. Persistence of developmental dyscalculia: What counts Results from a 3-year prospective follow-up study. J Pediatr 1998; 133: 358-362.
4. American Psychiatric Association. Diagnostic and statistical manual of mental disorders, 4th ed. Washington, DC; American Psychiatric Association, 1994.
5. World Health Organization. The international classification of diseases, vol. 10: classification of mental and behavioural disorders. Geneva: World Health Organization, 1993.
6. Demonet JF, Taylor MJ, Chaix Y. Developmental dyslexia. Lancet 2004; 363:1451-1460.
7. Katusic SK, Colligan RC, Barbaresi WJ, Schaid DJ, Jacobsen SJ. Incidence of reading disability in a population-based birth cohort, 1976-1982, Rochester, Minn. Mayo Clin Proc 2001; 76: 1081-1092.
8. Ramaa S, Gowramma IP. A systematic procedure for identifying and classifying children with dyscalculia among primary school children in India. Dyslexia 2002; 8: 67-85.
9. Santos OB. Language skills and cognitive processes related to poor reading comprehension performance. J Learn Disabil 1989; 22: 131-133.
10. Riley NJ. Piagetian cognitive functioning in students with learning disabilities. J Learn Disabil 1989; 22: 444-451.
11. Masutto C, Cornoldi C. Cognitive profiles and deviation patterns of dyslexic children. Percept Mot Skills 1992; 75: 15-18.
12. Das JP, Mishra RK, Kirby JR. Cognitive patterns of children with dyslexia: a comparison between groups with high and average nonverbal intelligence. J Learn Disabil 1994; 27: 235-242.
13. Taylor RL, Warren SA. Educational and psychological assessment of children with learning disorders. Pediatr Clin North Am 1984; 31: 281-296.
14. Bhatt MC. Adaptation of the Wechsler Intelligence Scale for Children for Gujarati population [PhD dissertation]. Ahmedabad (Gujarat); Univ. of Gujarat, 1971.
15. Deno SL, Fuchs LS, Marston D, Shinn M. Using curriculum-based measurement to establish growth standards for students with learning disabilities. School Psych Rev 2001; 30: 507-524.
16. Jnana Prabodhini's Institute of Psychology. Construction of a battery of tests based on Structure of Intellect Model by J P Guilford. Pune; Jnana Prabodhini, 1985.
17. Guilford JP, ed. The nature of human intelligence. 1st ed. New York; McGraw-Hill, 1967.
18. Dakin KE. Educational assessment and remediation of learning disabilities. Semin Neurol 1991; 11: 42-49.
19. Das JP, Mishra RK, Pool JE. An experiment on cognitive remediation of word-reading difficulty. J Learn Disabil 1995; 28: 66-79.
20. Temple CM. Cognitive neuropsychology and its application to children. J Child Psychol Psychiatry 1997; 38: 27-52.
21. Montague M. Cognitive strategy instruction in mathematics for students with learning disabilities. J Learn Disabil 1997; 30: 164-177.(Karande Sunil, Sawant Sul)
Abstract
Objective: To compare the cognition abilities of children with specific learning disability (SpLD) viz. dyslexia, dysgraphia and dyscalculia with those of non-impaired children. Methods : The study group consisted of 95 newly diagnosed SpLD children (aged 9-14 years) and the control group consisted of 125 non-impaired children (aged 9-14 years). An academic achievement of two years below the actual grade placement on educational assessment with a Curriculum-Based test was considered diagnostic of SpLD. A battery of 13 cognition function tests based on Guilford's Structure of Intellect Model was administered individually on each child in four areas of information viz. figural, symbolic, semantic and behavioral. Mean scores ± SD obtained in these four areas were calculated in both groups and compared using Independent Samples t-test. A P value < 0.05 was considered significant. Results : Children with SpLD had significantly lower scores (mean ± SD) in all four areas of information: maximally in the symbolic area (18.66 ± 4.83 vs. 28.30 ± 4.29, mean difference 9.64, P< 0.0001, df = 218, 95% CI 8.43-10.86), followed by semantic (18.72 ± 5.07 vs 27.36 ± 4.17, mean difference 8.64, P< 0.0001, df=218, 95% CI 7.40-9.87), figural (17.10 ± 5.24 vs 25.14 ± 3.36, mean difference 8.04, P< 0.0001, df=218, 95% CI 6.89-9.19), and behavioral (5.68 ± 2.10 vs 7.54 ± 1.46, mean difference 1.86, P< 0.0001, df = 218, 95% CI 1.39-2.33) areas. Conclusion : Cognition abilities are significantly impaired in children with SpLD.
Keywords: Cognition disorders; Dyslexia; Mainstreaming (Education); Remedial Teaching
Specific learning disabilities (SpLD) is a generic term that refers to a heterogeneous group of disorders manifested by significant unexpected, specific and persistent difficulties in the acquisition and use of efficient reading (dyslexia), writing (dysgraphia) or mathematical (dyscalculia) abilities despite conventional instruction, intact senses, normal intelligence, proper motivation and adequate socio-cultural opportunity. [1],[2],[3] The term SpLD does not include children who have learning problems which are primarily the result of visual, hearing, or motor handicaps, of subnormal intelligence, of emotional disturbance, or of socio-cultural disadvantage.[4],[5] Although still a mater of debate, this exclusionary definition has been adopted by the diagnostic and statistical manual of mental disorders (DSM-IV) and the international classification of diseases (ICD-10), classification of mental and behavioral disorders.[4],[5]
SpLD are one of the most common neurobehavioral disorders in children. [1],[2],[3] They constitute an invisible handicap and are important causes of poor school performance. [1],[2],[3] They are intrinsic to the individual and are presumed to be due to central nervous system dysfunction.[6]
Dyslexia (or specific reading disability) is the most common and most carefully studied of the learning disabilities, affecting 80% of all those identified as learning-disabled.[2] The incidence of dyslexia in school children in USA ranges between 5.3- 11.8%.[7] Substantial evidence has established that dyslexic children have deficits in "phonologic awareness", which consistently distinguish them from those who are not reading-impaired.[6] According to this "phonologic-deficit hypothesis", dyslexic children have difficulty developing an awareness that words, both written and spoken, can be broken down into smaller units of sound and that; in fact, the letters constituting the printed word represent the sounds heard in the spoken word.[6]
Information on SpLD in Indian children is scanty. A recent study from South India has reported the incidence of dyscalculia to range between 5.5- 6% in primary school children.[8]
Cognition is an intellectual or mental process of acquiring knowledge and it plays an important role in learning. Cognition disorders are disturbances in the mental process related to thinking, reasoning, and judgment. Studies done in USA, Canada and Italy have reported that children with SpLD have cognition disorders. [9],[10],[11],[12]
Since 1996, the authors have been running a Learning Disability clinic which is the sole Certification Centre recognized by the State Ministry of Education, Government of Maharashtra. The present study was conducted to assess cognition abilities in children with SpLD, and to compare their cognition abilities with those of non-impaired children. This study has been conducted considering that there is no knowledge of such a study being reported from India.
Materials and methods
Selection of Cases
This case-controlled cross-sectional study was conducted over a period of 15 months, from January 2001 to March 2002. The study group consisted of children, aged nine years and above, and in whom SpLD were newly diagnosed, i.e. they had not yet undergone remedial education. Currently, SpLD cannot be conclusively diagnosed until the child is about eight to nine years old.[2] These SpLD children were attending English medium schools in the city of Mumbai and nearby districts and had been referred to learning disability clinic by their school principals with complaints of poor academic performance.
First, audiometric and ophthalmic examinations were done to rule out hearing and visual deficits. Children in whom non-correctable hearing or visual deficits were detected did not qualify for a diagnosis of SpLD.
Each child was assessed by a multidisciplinary team comprising of Pediatrician, Counselor, Clinical Psychologist and Special Educator before the diagnosis of SpLD was confirmed.[1],[13] The Pediatrician took a detailed clinical history and did a detailed neurological examination. The Counselor took a thorough social history to rule out emotional problem that could have been primarily responsible for the child's academic underachievement. If severe emotional disturbances, or depression, or attention deficit hyperactivity disorder (ADHD) were suspected the child was also assessed by a Child Psychiatrist. Children diagnosed with severe emotional disturbances or depression were not enrolled in the study, as these children needed to be first treated for a few months for these conditions before assessment for SpLD could be done.[1]
The Clinical Psychologist conducted the standard test for determining the child's level of intelligence (i.e. intellectual potential) viz. Wechsler Intelligence Scale for Children-Revised (WISC) (Indian adaptation by MC Bhatt).[14]
Employing a locally developed Curriculum-Based test, the Special Educator (RS) conducted the educational assessment in specific areas of learning viz basic learning skills, reading comprehension, oral expression, listening comprehension, written expression, mathematical calculation and mathematical reasoning. An academic achievement of two years below the actual grade placement was considered diagnostic of SpLD.[1],[13] Curriculum-based assessment is a recommended method of assessing a child's academic achievement.[13],[15] This test is a criterion-referenced test devised by the Learning Disability clinic's Special Educator (RS) and is based on the curriculum followed in Mumbai schools.
In the clinic, since both the WISC test and the Curriculum-Based test are conducted in English, children in whom "language barrier" was suspected to be the cause of poor school performance, i.e., those who were not conversant in English as they came from non-English speaking families, could not be assessed for SpLD.
Children diagnosed with SpLD and having co-morbid conditions which are known to impair cognitive functioning viz ADHD or epilepsy being treated with antiepileptic drugs were also excluded from the study.[1]
The control group consisted of non-impaired children and was selected from a nearby English medium school. For inclusion in the control group, the classroom teacher was consulted to ensure that the child did not have a history of academic underachievement or any current schooling problems or epilepsy being treated with antiepileptic drugs.
Cognition Function Tests
All children enlisted in the study were in good health. Informed consent was taken from their parents to undergo the cognition function tests (CFTs). One of the authors (SS) administered a battery of 13 CFTs on each child individually. These psychometric tests have been devised by Jnana Prabodhini's Institute of Psychology, Pune, with support of the National Council of Educational Research and Training (NCERT), New Delhi, and are based on the Guilford's Structure of Intellect (SOI) Model.[16],[17] These tests have been standardized after administering them to over 300 school children.[16] The tests' kit is available from: Jnana Prabodhini, 510 Sadashiv Peth, Pune 411 030, India
These 13 CFTs assessed cognition in four areas of information table1: figural (code numbers 112, 113, 114), symbolic (code numbers 121, 122, 125), semantic (code numbers 131, 133, 134, 135, 136), and behavioral (code numbers 141, 146). Each of these 13 CFTs comprised of sub-tests which tested the same specific cognitive function. This ensured that the test scores obtained by the child were valid and not due to chance.[16]
Each test had two sample questions. As recommended, each child was explained about these two examples before he / she undertook the test.[16] Generally, the sequence for the CFTs was: first, tests of figural information, then symbolic, semantic and finally behavioral. However, the child was allowed to alter this sequence if so desired, as this in no way influences the scores.[16] As recommended: while undergoing these 13 tests the child was not allowed to: (i) answer another test without having completed the one being administered, or (ii) change the answer of any previously administered test. There were no time constraints for completing the CFTs, and a child had the freedom to leave a test without answering all its sub-tests if he / she found it difficult. It took about 60 to 90 minutes for a child to complete the CFTs.
Data Analysis
Each child's CFTs scores were calculated in these four areas of information. The maximum marks a child could score were 116. The data obtained was analyzed using the Statistical Package for the Social Sciences, version 7.5 for Windows (SPSS Ltd., Chicago, Illinois, USA). Mean scores ± SD obtained in these four areas of information were calculated in both groups of children. Results obtained were compared using Independent Samples t-test. A P value< 0.05 was considered significant. Two-tailed significance was obtained in all cases.
Results
A total of 95 children with SpLD were included in the present study. Their age ranged from 9-14 years table2, with mean age 12.32 years (SD, 1.48). There was a male preponderance in the study group, with a male: female ratio of 3.8: 1. A diagnosis of dyslexia was made in 94/95 (98.9%), dysgraphia in 92/95 (96.8%), and dyscalculia in 89/95 (93.7%). However, most of the children in the study group viz 86/95 (90.5%) had all three types of SpLD present concomitantly.
In the control group, 125 non-impaired children were included. Their age ranged from 9-14 years table2, with mean age 11.83 years (SD, 1.73). Their male: female ratio was 1.1:1.
Children with SpLD had significantly lower scores in each of the 13 CFTs table3a. When the overall CFTs scores in the areas of information were compared in the two groups table3b, children with SpLD had significantly lower scores in all four areas of information ( P < 0.0001). However, their cognition was impaired maximally in the symbolic area (mean difference in scores was 9.64), followed by semantic, figural and behavioral areas of information table3b.
Discussion
Employing psychometric tests based on the Guilford's SOI Model, the present study has documented that Indian children with SpLD have significantly impaired cognition abilities. Also, the present study has identified that their cognition is impaired maximally in the symbolic area of information, followed in descending order by semantic, figural and behavioral areas of information.
It is well known that children with SpLD exhibit a severe discrepancy between their intellectual potential and academic achievement. [1],[2],[3] SpLD is not just a school disability, it is a life-time disability. The same dysfunctions that interfere with normal learning processes may also have impact on self-image, peer and family relationships, and social interactions. [1],[2],[3] However, if SpLD is diagnosed and treated early, the child has the potential for a reasonably successful future. The cornerstone of treatment of SpLD is remedial education. [1],[2],[3]Hence, early referral to a Special Educator for remedial education when the child is in primary school is crucial. [1],[2],[3]
Using specific teaching strategies and teaching materials, the Special Educator formulates an Individual Education Program (IEP) to reduce, eliminate or preclude the child's deficiencies in specific learning areas such as reading, writing and mathematics identified during the child's educational assessment. The child has to undergo these "remedial" sessions twice or thrice weekly, during which he/she undergoes systematic and highly structured training exercises to learn that words can be segmented into smaller units of sound ("phoneme awareness"), and that these sounds are linked with specific letters and letter patterns ("phonics").[2],[18] The child also requires practice in reading stories, both to apply newly acquired decoding skills to reading words in context and to experience reading for meaning.[2] Although remedial education concentrates almost exclusively on trying to impart academic skills by "teaching around" disabilities, it is known to alleviate underlying cognitive problems and help achieve academic competence.[12],[18] However, remedial education is expensive (one session costs ~Rs.250/-) and the child needs to undergo it for a few years (two to five) till he / she learns to largely overcome the disability.[2],[18]
What is the utility of the present study First, it is postulated that these CFTs can be used by Special Educators to objectively assess the progress being made by a child undergoing remedial education. The authors suggest that every child should perform on these CFTs at the time SpLD is diagnosed, i.e. before remedial education is begun. After the child has undergone remedial education for at least a year, which is usually the average minimum time required for it to start showing benefit, the child should again perform on these CFTs. The authors believed that the child's scores on the follow-up CFTs would then be higher. This would be an objective assessment of the effectiveness of remedial education which would reassure the child's parents of the utility of this rather expensive therapy. The improved scores would convince them to continue their child's remedial education, and this would enable the child continue education in a regular mainstream school. The authors follow-up research on the same subjects is examining this postulation. Second, we suggest that in addition to the regular remedial education sessions that address phonological coding, children with SpLD should also simultaneously undergo strategic interventions to alleviate their impaired cognition, especially in the symbolic and semantic areas of information. In recent years in Canada, USA and UK "cognitive remedial therapy", given along with the regular remediation education, is being increasingly recognized as an effective method to optimize the rehabilitation of children with SpLD. [19],[20],[21]
Two potential limitations of the present study need to be mentioned. First, the two groups could not be gender-matched table2. It is well known that more boys than girls are referred for detection of SpLD, and the authors could not overcome this limitation.[7] Second, the present study was restricted to measuring "cognition", which is the first of the five intellectual operations described by Guilford to describe intelligence.[17] The other operations, viz., memory (retaining and recalling the contents of thought), convergent production (producing a single best solution to a problem), divergent production (producing a variety of ideas or solutions to a problem) and evaluation (deciding whether the intellectual contents are positive or negative, good or bad) have not been evaluated by the authors. However, there is no reason to believe that this adversely affects the utility of the present results, as Guilford has clearly stated that each of the five operations function independently.[17]
The authors cannot compare the present study with previous work because there is no such study. A detailed Medline / PubMed search did not find any such study, in India or elsewhere, which has analyzed cognition in children with SpLD using tests based on the Guilford's SOI Model.
In summary, the present study documents that Indian children with SpLD have significantly impaired cognition abilities. Additional studies are required in various parts of the country to determine the generalization of these results.
Acknowledgements
The authors thank the Dean, Dr. M.E. Yeolekar for granting permission to publish this study. Thanks are due to the Principal, Jnana Prabodhini's Institute of Psychology, Pune for granting us permission to use their Cognition Function Tests for the present study; Rajiv Gandhi Foundation, New Delhi for its grant for Learning Disability Clinic; the Principal, V.N. Sule Vidyalaya, Mumbai for allowing to enlist children who comprised the control group; and Dr. D.P. Singh, Reader, Department of Research Methodology, Tata Institute of Social Sciences, Mumbai for his help in the statistical analysis of the data. Lastly, the authors thank the children who participated in this research project.
Contributors
SuK initiated and designed the study, directed the data analysis and wrote the manuscript; he will act as the guarantor of the paper. SS conducted the Cognition Function Tests, performed the literature review, and edited the manuscript. MK helped in designing the study, discussed the core ideas and analysis, and edited the manuscript. SaK helped in literature review and data analysis, discussed the core ideas, and edited the manuscript. RS helped in designing the study, conducted the educational testing, discussed the core ideas and analysis, and edited the manuscript.
Funding: None.
Competing Interests: None.
This paper is based on the dissertation submitted to University of Mumbai for MD (Pediatrics) degree examination held in January 2003. Sunil Karande was the postgraduate dissertation guide and Sulaxna Sawant was the postgraduate student.
This paper was presented as a Poster Presentation at the "8th Asian & Oceanian Congress of Child Neurology", organized by the Asian & Oceanian Child Neurology Association, Indian Academy of Pediatrics- Child Neurology Chapter and Association of Child Neurology, held at New Delhi, India, October 7-10, 2004.
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