PHONIATRICS Learning disability CORRECTED

Audience

Strong recommendation

Conditional recommendation

Patients

Most individuals in this situation would want the recommended course of action; only a small proportion would not.

Formal decision aides are not likely to be needed to help individuals make decisions consistent with their values and preferences.

Most individuals in this situation would want the suggested course of action, but many would not

Clinicians

Most individuals should receive the intervention.

Adherence to the recommendation could be used as a quality criterion or performance indicator.

Different choices will be appropriate for individual patients, who will require assistance in arriving at a management decision consistent with his or her values and preferences. Decision aides may be useful in helping individuals make decisions consistent with their values and preferences.

Policymakers

The recommendation can be adopted as policy in most situations.

Policy-making will require substantial debate and involvement of various stakeholders.

Grade

Definition

High

We are very confident that the true effect lies close to that of the estimate of the effect.

Moderate

We are moderately confident in the effect estimate: the true effect is likely to be close to the estimate of the effect, but there is a possibility that it is substantially different

Low

Our confidence in the effect estimate is limited: the true effect may be substantially different from the estimate of the effect.

Very Low

We have very little confidence in the effect estimate: the true effect is likely to be substantially different from the estimate of effect

Clinical questions

Action recommendation

Evidence Quality

Strength of Recommendation

Study type

References

1.Criteriafor a Diagnosis of Learning Disability

Specific Learning Disability means a disorder in one or more basic psychological processes involved in understanding or in using language,  spoken or written that may manifest itself nan imperfect ability to listen ,think, speak, read, write, spell, or do mathematical calculations in spite of normal sensory channels, intact psyche, normal cognitive abilities and given opportunity”.

 Very Low

 Conditional

 Expert opinion

(Review article)

 3

2.Historyof academic impairment

History of academic functioning below the level typically expected for individuals of the same chronological age, and it is based on the difference between a child’s cognitive ability and his/her present academic achievement score or the need for excessive time or support to develop or maintain typical levels of academic functioning, as judged by the parents and educators.

Moderate

Strong

Systematic review

             4

3.Evidencethatthe difficulties in reading, writing ,or mathematics cannot be accounted for primarily by other factors

Other conditions or disorders(e.g., intellectual disabilities, uncorrected visual  or  auditory  acuity,  physical or chronic health disabilities, other neurodevelopmental               disorders, or disruptive behavior disorders (internalizing or externalizing disorders)- Environmental factors(e.g. Psychosocial adversity, inadequate or inappropriate educational instruction) through history taking:

-Insufficient motivation or effort through history taking or observation through his performance in the applied tests;

-Cultural or linguistic diversity through history taking.

Low

Case-Control study

      5

Clinical questions

Action recommendation

Evidence Quality

Strength of Recommendation

Study type

References

4.Assess abilities essential for thinking and reasoning.

 These tests include the Wechsler tests, Stanford Binnet (The Arabic versions of WechslerandStanfordBinnet5thedition).

**Standard scoresthatarebetween85 and115 (i.e. Within one standard deviation of the mean) should be considered to be average and is an essential criterion for diagnosis of specific learning disability.

Moderate

Systematic review

6

5.Assess and rule out other factors that could better explain the pattern of results, including Effort ,motivation and non-compliance with instructions

Subjective impression is mandatory by parents, teachers and even clinicians for effort done by the child, motivation and compliance.

Low

Observational study

7

6.Evidence of risk factors for LD and other learning difficulties

Risk factors for LD identified within

International research include:

•heritability of reading disabilities

•prenatal ,Newborn or postnatal risk factors

•Available Arabic test battery for LD) can pose a light on the child different psychological processing aptitude responsible for LD.

Moderate

          8

9

•slow development of reading decoding

Skills in culturally and linguistically diverse individuals.

7.Assess academic achievement

A core aspect of the definition of LD is that the individual’s academic achievement is below average(i.e.,at least one standard deviation below the mean)in at least one of:

Reading- indicated by  any of :

-PA(phonologic awareness test)

 -MADST(Modified Arabic                 Dyslexia Screening Test)

-ARST(Arabic Reading Screening Test) Writing–MADST-Dysphagia Severity scale

Mathematics- indicated by any of Calculation, including but not limited to: numeracy, algebra, geometry and calculation  fluency; applications  such  as the understanding of time, money, measurement, data analysis; and word problem-solving including geometry and data interpretation.

Very Low

And this can be followed up with the

child’s grades at school depending on the school academic testing.

Clinical questions

Action recommendation

Evidence Quality

Strength of Recommendation

Study type

References

8.Assesscomorbid emotional and  behavioral problems documented by clinical judgment and testing

-Individuals with LD are at increased risk for social, emotional and behavioral difficulties.

In some cases, these difficulties are associated with ADHD which is frequently comorbid with LD).

(Conner’s test can be recommended to aid diagnosis)

Low

Observational Study (Cohort)

9.Developa formulation and diagnostic statement in accordance with the above criteria for a diagnosis of LD

From the Phoniatric point of view, Supple (2000) categorized language-based learning disabilities into:

(1) Lower order process disorders: Phonological awareness-Phoneme- grapheme correspondence

(2)Higher order process disorders: Vocabulary including word finding difficulty

Semantic deficit

Syntactic deficit

(3) Attention & Memory deficits

The development of a clear diagnostic statement     requires      the     results of  many  clinical  tests      including: Language testing

• Psycholinguistic ability test

• Psychical awareness test

•  Dyslexia test

•  Reading test

• Dysgraphia Severity scale.

      11

Clinical questions

Action recommendation

Evidence Quality

Strength of Recommendation

Study type

References

10.Identify the types of evidence-based and realistic supports and interventions that are required

Recommendations for intervention are most likely to be comprehended and implemented when there commendations are “SMARTS”: Specific and clear, according to the profile of strengths and weaknesses of the child, Measurable, Applicable to the individual’s needs, Realistic to implement in the context, Timely, and Supported by research.

Very Low

12

Put objectives and reassess after 3-6

Months for child’s achievement in the specifically designed program of therapy in areas of weakness.

11.Communicate the results of the assessment, the diagnosis and recommendations

Results of the assessment must be discussed with parents, teachers and even with the older children.

By grade 3 if the child is not able to read it is a challenge to close the gap and great efforts has to be done by the child, his family, therapist and teachers.

Very Low

Expert Opinion

(Review article)

13

12.Theoptimalageto firstscreens for and diagnoses LD?

-Age of psychometric, language assessment and psycholinguistic ability tests is by kindergarten entry (4 years).

IQ involve effective screening of all children in kindergarten and grade one for early identification and to optimize access to early intervention. Those determined to be at risk, based on low early literacy (e.g., phonemic processing)and numeracy skills, and are then provided with evidence-based intervention in kindergarten and the early grades. Age of phonologic awareness assessment is by (5.5years).

Ageofdyslexiascreeningisby6.5 years.

Interventions are delivered in the regular classroom or in small groups.

However, if a child is struggling academically and has gone unidentified or unsupported during grade one, assessment to indicate  the  nature of difficulties to guide intervention is essential.

Waiting until the end of grade two may reduce the effectiveness of future interventions (By the end of second primary (8years) the gap would be very wide with poorer prognosis so our chance is in the early years).

So by kindergarten entry, if suspect SLD, tests could be applied and proceed in therapy either in main stream or in small groups or even one-to-one.

moderate

Systematic review

14

Clinical questions

Action recommendation

Evidence Quality

Strength of Recommendation

Study type

 References

 13.Childrenat disproportionate risk for learning challenges

Such as children with early symptoms or diagnosis of

- ADHD.

-DLD, ASD.

-Children with complex medical conditions: (e.g. extreme prematurity, congenital heart disease).

-Early brain injury (e.g .Newborn stroke, brain tumor, traumatic brain injury).

- Epilepsy.

Children with learning co-morbidities will also benefit from early assessment with a focus on contributing to school-based support.

Very Low

Review article

(Expert opinion)

15

14- Whatadaptations are required for assessments of Culturally and Linguistically Diverse (CLD) individuals experiencing learning difficulties as  regard language and literacy skills

For the First (L1) and Second (L2)

learners

• Consider a diagnosis of LD in L2 individuals who have hardwood more years of English or French reading instruction and have below average word-level reading and spelling skills.

•Examine the types of errors that individuals make on language Consider positive transfer(e.g., they may use words that are similar intheirL1to understandtheL2),and negative transfer (they may apply grammatical structures that are correct in theirL1 totheirL2 when that is not appropriate).

•Compare the functioning of the individual with siblings from the same context.

•Assess in the individual’s first language

When appropriate.

•Assess cognitive processes(phonological processing, rapid automatized naming “RAN”, and non-word repetition).

•Consider that If phonological processing scores are below average that this may represent a Learning Disability, rather than being due to English language learning “ELL” status alone.

•Supplement standardized cognitive and achievement tests including nonverbal test with few instructions and use clinical judgment when interpreting test scores.

Cohort study

16

Clinical questions

Action recommendation

Evidence Quality

Strength of Recommendation

Study type

References

 15.Social,Emotional and Behavioral Assessment in CLD Individuals

•The following strategies are recommended to decrease cultural and linguistic loading for CLD.

• Use multiple sources (self- family and teacher reports)and methods (observations, interviewing, formal objective rating scales, and informal projective tests such as drawings and sentence completions).

•Use standardized rating scales written in the individual’s or parent’sL1.

-Consider acculturation effects(i.e. Effects of cultural modification of CLD individuals caused by merging of cultures).

•Analyze narratives provided by the individual and family members.

-Be sensitive to signs of post-traumatic stress disorder “PTSD”, and other disorders that are associated with loneliness, trauma, and immigration struggles. 

Very Low

Strong

Book chapter

(Expert opinion)

17

16.Issuesshould be considered when diagnosing LD in individuals  with very superior intellectual ability

Above average intelligence does not negate the possibility of having areas of strengths and weaknesses in major areas of academic functioning and psychological processing.

Maddocks (2018) found that children with high IQ could be diagnosed as LD when taking into consideration both intra- individual ability- achievement discrepancy criteria and academic impairment.

Moderate

Strong

Systematic review

18

Clinical questions

Action recommendation

Evidence Quality

Strength of Recommendation

Study stype

references

 Early identification

 Early identification and intervention can lead to better prognosis.

Moderate

 Strong

Systematic review

Systematic review

19

20

 Reading strategies

Effective reading

instruction should include elements that teach five

critical areas of literacy:

(a)Phonemic awareness.

(b)Phoneme grapheme correspondence.

(c) Decoding (Alphabetic reading).

(d) Fluency (Automatic decoding=orthographic reading).

(e)Text comprehension, with care for vocabulary store, semantics, syntax.

*This program is applicable to SLD children(IQ=

85-115) and slow learners (IQ= 70-84).

*Slow learners can benefit from  the same reading strategies ,except that phonological awareness training would be difficult owing to their impaired cognitive abilities, codirect instruction in phoneme-grapheme correspondence would be recommended.=3.6.

 moderate

moderate

Systematic review

Systematic review

21

22

Reading fluency

striges

The followings are evidence-based

fluency interventions:

• Repeated readings of the same passage.

•  Vocabulary instruction (Words that are useful to know and are likely to appear in variety of settings may have the widest impact.).

• Choral reading.

• Partner reading.

• Tape-assisted reading.

• Training for rapid automatized naming.

Very Low

 Expert opinion

(Review article))

 23

Clinical questions

Action recommendation

Evidence Quality

Strength of Recommendation

Study type

reference

 Reading Comprehension-on strategies

• Improving listening and reading comprehension (through vocabulary “WFD tuning”, semantics, and syntax).

• Direct instruction on Background Knowledge.

•  Graphic Organizers.

• Explicit instruction of Text Structure.

•  Finding the Main Idea.

• Summarization.

• Question-Answer Relationships Strategy.

•  Self-Questioning Strategies.

•  Reciprocal Teaching.

•  Collaborative Strategic Reading.

*Attention (auditory and visual) and short term/ working memory training helps maintenance and retrieval of knowledge.

*Regarding hearing impaired children, improving comprehension through training higher order processes (including vocabulary, semantics and syntax) should be emphasized. Provision of phonological awareness training should be limited to cases with good auditory abilities (i.e. cochlear implanted cases).

Very low

moderate

moderate

Strong

strong

Strong

(Review article)

Systematic review

Research based

practice

24

25

26

 Written language strategies

Three written language skills:

(1) Handwriting.

(2)Spelling.

(3)Written expression .Although one skill influences the other, students may have problems in one area but not in the others.

For handwriting

direct, explicit instruction of letter formation and guided practice with the use of a multisensory approach is recommended.

For spelling,   multisensory approach   (using visual, auditory, tactile, and kinesthetic modalities) and reading remediation is recommended.

Written expression through sentence writing strategy and sentence-combining strategy.

It is important to differentiate whether dysgraphia is dyslexic, motor, or spatial. Occupational therapy may help motor and spatial types.

 moderate

Very Low

Strong

 Systematic review

 27

28

 Mathematics strategies

Explicit instruction should be provide during manipulative, cognitive strategies ,using visual representations while solving mathematical problems, using graphic organizers to solve systems of linear equations, etc.

 Moderate

 Strong

 systematic review

29

30

Clinical questions

Action recommendation

Evidence Quality

Strength of Recommendation

Study type

reference

Social studies   and science strategies

Effective strategies include:

-Pre teaching vocabulary before introducing a unit.

-Mnemonic (memory enhancing) instruction.

-Giving students outlines, semantic webs or a graphic organizer of key information.

-Getting acquainted with Tier III words(which are

Low-frequency, subject-specific words).

Systematic review

31

Accommodations

Accommodations are consideredtobe “changes to the delivery of instruction, method of student performance, or method of assessment that do not significantly change the content or conceptual difficulty level of the curriculum”.

Examples of accommodations

Include:

a) Use of mnemonics strategy. b)Cooperative learning groups.

c) Modeling procedures.

d)Word processors.

e) Providing preferential seating.

f)Providing special lighting or acoustics. g)Oralversus written response.

h)Administering a test in several timed sessions.

i) Use of assistive technology.

Systematic review

32

 Modifications

Modifications are changes to the curricular content, changes to the conceptual difficulty level of the curriculum, or changes to the objectives and methodology. These involve more significant changes than accommodations.

moderate

Systematic review

32

Classroom management

Establishing routines can reduce students ‘working memory overload. The use of visual clues, modeling and rehearsal of desired behaviors, breaking tasks into subtasks can also address working memory problems.

Classroom management may be somehow difficult in Egypt.

 Moderate

Systematic review

33

Clinical questions

Action recommendation

Evidence Quality

Strength of Recommendation

Study type

reference

 Adolescents with

SLD

*Motivation

* A student with SLD should be involved in transition planning and have an individualized transition plan no later than age 14.

*Promoting self-determination which includes characteristics such as assertiveness, self- advocacy, and independence.

* Preparing adolescents with SLD for transition from high school to adulthood is one of the goals of instruction, to enable them to advocate for their rights and prerogatives.

Dealing with adolescents with SLD is questionable in Egypt.

moderate

moderate

strong

Strong

Systematic review

Systematic review

 Students from diverse backgrounds with SLD

Use of visuals and graphics, repetition and paraphrase, pre-teach vocabulary, audiotape the text, having a word bank for assignments that require short answers.

Providing written directions along with oral directions, use more pauses within a lesson.

Brainstorming, “think-pair-share”, peer tutoring.

Moderate

 moderate

strong

Strong

Systematic review

Systematic review

 The Twice- Exceptional Students

*Twice-exceptional students are those learners who meet criteria for being identified as both gifted and having a specific learning disability.

* Teachers must consider the students ‘strengths (e.g., problem solving, metacognition)and problem areas(e.g., basic skills, organization). Twice-exceptional   students    need    teachers who will provide them with emotional support, effective         instruction,        accommodations. (e.g., calculators, spell-checkers),and skills for self-advocacy.

moderate

moderate

Systematic review

Systematic review