Learning difficulties in children attending a special clinic at the Lady Ridgeway Hospital

Method Children diagnosed to have learning difficulties or attention deficit hyperactive disorder (ADHD), presenting to CPGC at LRH from 27 May to 10 June 2003, were included in study. Learning difficulties were diagnosed by a child psychiatrist using DSM IV criteria. A pre-tested, interviewer administered questionnaire (IAQ) was used to collect socio-demographic data, details on health-seeking behaviour and modes of referral from parents/ guardians. A checklist was used to identify presentations.


Introduction
For many children learning is a happy and enjoyable experience but some have learning difficulties.According to DSM IV, learning, communication and ___________________________________________ 1 Medical student, 2 Senior Lecturer, Dept. of Pharmacology, Faculty of Medicine, University of Colombo.
(Received on 15 October 2003) motor skills disorders are classified under learning difficulties 1 .Though technically not considered a learning difficulty there is a co-morbidity rate of 10-60% between Attention Deficit Hyperactive Disorder (ADHD) and learning difficulties 2 .It is estimated that 5% school children and 50% children attending child psychiatry clinics in United States of America (USA) have learning difficulties 1 .Sri Lankan prevalence for learning difficulties is not known but a study done by Kariyawasam et al 3 found ADHD a significant problem in Sri Lanka.
By definition, learning difficulties exclude sociocultural factors that may affect child's learning 4,5 However, poor socio-economic conditions are associated with malnutrition, limited prenatal and postnatal care, exposure to teratogens and maternal substance abuse which can lead to subtle neuropsychiatric disturbances giving rise to learning difficulties 6 .Recent studies have shown that characteristics of child's immediate environment have an impact on his maturation and indirectly on learning as well 7 .
Recognition of the true characteristics of children with learning difficulties will lead parents and teachers to deal with them in a sympathetic yet effective manner 7 .DSM IV gives criteria for diagnosis of learning difficulties 1 .Subtle characteristics and their predictability as high, moderate and weak have been described which may help identify children with learning difficulties 8,9 .Unfortunately these children are often not identified till late.This delays benefits of interventional care.If doctors, teachers and parents are vigilant about these characteristics, they can be identified early.
Early intervention for learning difficulties is warranted for maximal potential outcome in these children 7 .In USA, where there is a proper network of interventional centres, different modalities of intervention have been studied and compared 10 .It has been recommended to establish regional healthcare teams that can liaise with the schools for the child neuropsychiatric disorders such as ADHD and other learning disabilities under the supervision of a paediatrician/psychiatrist 3 .

Method
A descriptive cross sectional study was carried out in the Child Psychiatry and Guidance Clinic (CPGC) at Lady Ridgeway Hospital (LRH) from 27 May to 10 June 2003.Study population consisted of all children, 5-14 years old, diagnosed by a child psychiatrist as having a learning difficulty or ADHD using DSM IV criteria with diagnosis stated in child's clinic records.Children with mental retardation, autism, visual or hearing disabilities, confirmed by written records at CPGC, and those without documented evidence of learning difficulties were excluded from study, CPGC functions twice weekly for 3 hours and about 20 children attend clinic each day.Considering feasibility of collecting data, a sample of 50 and a study period of 2 weeks was decided upon.An interviewer-administered questionnaire (IAQ) was used to assess sociodemographic characteristics, health seeking behaviour and modes of referral of children with learning difficulties.An interviewer-administered checklist (CL) was used to identify features at presentation.CL was devised using DSM IV criteria 1 , child psychiatry text books 6,11 and related research articles 8,9 .Both IAQ and CL were subjected to a focus group discussion of parents and teachers from Centre for Individuals with Learning Difficulties at Narahenpita.To minimize errors, IAQ comprised both open and close-ended questions, in a simple format, relating to a sequence approach to events, to improve recall.IAQ and CL were also subjected to the retranslation technique to improve validity and assess degree of agreement.To minimise errors in data transfer, a code column was included in IAQ.Medical students involved in study administered questionnaire after a training session.Both IAQ and CL were validated by a pretest on a sample of 5 children each, with and without learning difficulties, in ward 4, LRH and Centre for Individuals with Learning Difficulties.Reading and writing were not assessed in children below 7 years of age and mathematics in children below 8 years of age, as these are the current international recommendations 1 .In collecting data, CPGC records were checked in all children presenting to clinic during study period, in the order of registration.After selecting children who met required criteria, an information leaflet on the study and its potential benefits was given to each parent/ guardian and informed verbal consent obtained.To maintain privacy, IAQ was individually administered in cubicles of the clinic room.Data was entered using Microsoft Excel Spread Sheet.Chi-square test was used to study significance of difference in socio-demographic characteristics.

c. Writing
As cut-off age to assess writing is 7 years it was assessed in only 41 children.Frequency of presentations with writing difficulties is shown in table 3.

e. Motor skills
This was assessed in all 52 children.Frequency of presentations with motor skills difficulties is shown in table 5.

Discussion
Reading difficulties were common presentations in children with learning difficulties in our study occurring in over 70% cases.Our results are compatible with those of Scarborough 8 .Mathematics is considered a good way of assessing learning difficulties as it objectively defines cut offs and is easily measurable 1 .In our study around 60% children presented with difficulties in mathematics.About 55% children presented with difficulties in writing.Difficulties in communication were presenting features in about 45% children.Around 50% presented with difficulties in motor skills.Attention deficit and hyperactivity were found in about 60% children in our study.
Many learning difficulties including ADHD have male preponderance 1 and the male to female ratio for ADHD in Sri Lanka is 3.6:13.In our study 85% children were male.The mean age in the study sample was 9 years.31% children had some deficits in schooling.75% of the children were from the Colombo and Gampaha districts, a not unexpected finding.54% were urban dwellers.The mother was the care-taker in 83% cases.In 98% cases the care-taker had at least a primary education and in 67% instances had done their ordinary level examination.This finding is encouraging as strategies for information are delivered through the care-taker whose education level is important for the receptivity of such information.92% of the families earned more than 3000 rupees a month.In 89% cases the family size was 5 or less and in 81% instances the sibling number was either one or none.
Association between socio-demographic characteristics and presentations was found to be significant only between a characteristic of reading (where words were added, omitted or distorted while reading) and the caretaker's education level.
In 89% cases the mother or teacher were responsible for identification of the child with the presentation disclosed.In a local study in 74% children the problems had been detected by parents or relatives 13 .Mean age of identification was 4.5 years.The time taken for the first intervention showed 2 peaks 50% taking less than 3 months and 46% taking more than a year.The first medically related action taken was to go to a specialist unit in 62% cases and the primary health care service in 31% instances.The psychiatrist (69%) and the paediatrician (60%) were the main people involved in the interventions.Of those who sought non-western interventions only 24% sought Ayurveda treatment before coming for medical interventions.Of those who sought treatment from CPGC only 23% attended the clinic for more than 6 months, probably implying good progress within a short time with the interventions provided at the CPGC although non-compliance with the passage of tine cannot be excluded.Similar levels of satisfaction have been noted in a local study 14 where 165 new referrals were recruited of whom 66% expressed satisfaction with the interventions provided.
The general public, with special emphasis on primary school teachers, should be educated on the common presentations of learning difficulties.Proper education for identification and referral should be given to parents.First contact care health providers, too, need education on the presenting features and the availability of interventional centres.

Limitations of study
• Ideal study population would have been new enrolments to clinic.However, sample size would then be significantly reduced.
• Due to time lapse between presentation and date of interview, information gathered would carry a recall bias.
• Ideally study should have been conducted in clinics of an array of consultants to represent true population.We restricted our study to a specific clinic to ensure uniform assessment.
• A larger study sample, though ideal, was not possible due to time constraints.

table 1 Table 1
As cut-off age to assess mathematics is 8 years, it was assessed in only 28 children.Frequency of presentation with mathematic difficulties is shown in table 2.

Table 3
d. CommunicationThis was assessed in all 52 children.Frequency of presentations with communication difficulties is shown in table 4.

Table 7
Number of family members who are working is shown in table 13.Type of job of family member is shown in table 14.
c. Deficit of schooling Deficit of schooling among children is shown in table 8. d District Distribution district-wise is shown in table 9. f.Care-taker Type of care-taker is shown in table 11. i. Monthly income Income level is shown in table 15.
Number of siblings of index child is shown in table 17.
m. ReligionDistribution by religion is shown in table19.
Person who identified is shown in table 20.
c. Time period taken for first interventionTime taken for 1st intervention is shown in table 22.First intervention is shown in table 24.