IACAPAP Textbook of Child and Adolescent Mental Health

DEVELOPMENTAL DISORDERS

Chapter

C.3

SCHOOL UNDERACHIEVEMENTAND
SPECIFIC LEARNING DIFFICULTIES
Sonali Nag & Margaret Snowling

Sonali Nag MPhil (ClinicalPsych), PhD
Newton International Fellow
at the University of York,UK & honorary head of the
Early Childhood and Primary
Education departments at The
Promise Foundation, India
Conflict of interest: none
disclosed

Margaret J Snowling FMed
Sci, FBA
Professor, Department of
Psychology, University of York,
Heslington, York, UK
Conflict of interest: none
disclosed

Finishing lessons at home

Acknowledgements: We would
like to acknowledge Elinor
Saiegh-Haddad for commenting
on the Arabic section of Table
C.3.2 and Ying Wang for the
Chinese language stimuli in
Table C.3.7.

This publication is intended for professionals training or practicing in mental health and not for the general public. The opinions
expressed are those of the authors and do not necessarily represent the views of the Editor or IACAPAP. This publication seeks todescribe the best treatments and practices based on the scientific evidence available at the time of writing as evaluated by the authorsand may change as a result of new research. Readers need to apply this knowledge to patients in accordance with the guidelines andlaws of their country of practice. Some medications may not be available in some countries and readers should consult the specific drug
information since not all dosages and unwanted effects are mentioned. Organizations, publications and websites are cited or linked toillustrate issues or as a source of further information. This does not mean that authors, the Editor or IACAPAP endorse their content or
recommendations, which should be critically assessed by the reader. Websites may also change or cease to exist.
©IACAPAP 2012. This is an open-access publication under the Creative Commons Attribution Non-commercial License. Use,
distribution and reproduction in any medium are allowed without prior permission provided the original work is properly cited andthe use is non-commercial. Send comments about this book or chapter to jmreyATbigpond.net.au
Suggested citation: Nag S, Snowling MJ. School underachievement and specific learning difficulties. In Rey JM (ed), IACAPAP
e-Textbook of Child and Adolescent Mental Health. Geneva: International Association for Child and Adolescent Psychiatry and Allied
Professions 2012.

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IACAPAP Textbook of Child and Adolescent Mental HealthA

child struggling in school causes concern. Difficulties with school tasks
can leave children frustrated and parents and teachers wondering about thebarriers that are preventing learning. Indeed, school underachievement is
one of the most common reasons for referral to a visiting specialist in school or
to a child guidance clinic. Underachievement may however be a symptom of
any number of cognitive, emotional and social difficulties. In this chapter wewill first review definitions of learning disorders and discuss issues surrounding
their diagnosis. Although there is a growing body of evidence about mathematicaland other non-verbal learning difficulties, our focus will be on literacy learning
difficulties for two reasons. First, they pose a significant barrier to achievement
across the curriculum and second, because substantial cross-linguistic information
is becoming available about their behavioral manifestations in different language
contexts, methods of assessment and intervention. We will also consider school
underachievement when it is secondary to other conditions and, for a small selectionof such syndromes, we discuss why this may be the case. We end the chapter witha discussion about priorities that low income communities can set, both for theidentification of children with specific learning difficulties and remedial support.

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CORE CONSTRUCTS
There are many core skills that support learning. These different
skills can be seen as multiple foundations for learning
A child’s performance can be examined in relation to each of themultiple foundations. We can expect the child’s profile of skills toshow a mix of strengths and difficulties
When children’s development is delayed in relation to at least oneof the factors contributing to learning, they may be considered atrisk for a learning difficulty. Conversely, when skills are generally
available or present to above average levels, they may act asprotective factors
The criteria used for the diagnosis of learning difficulties aremoderated by the learning context
Learning difficulties are a dimensional construct – children withdifficulties fall along a continuum, some show less difficulty andothers more
Criteria used for diagnosis may separate children who have alearning difficulty from those who do not. This is a categoricalapproach to understanding learning difficulties. The approach is
popular, but it is important to note that cut-off criteria differentiating
at-risk/not-at-risk children are arbitrary.
There are distinct and specific learning difficulties that comprise acluster of recognisable behaviours. Examples of specific learning
difficulties (SLDs) are dyslexia (a difficulty with reading-related skills)
and dyscalculia (a difficulty with numerical skills)
SLDs can be present with other co-occurring problems or comorbidities. Examples of co-morbid problems include speech andsound disorders, attention deficit disorders and emotional disorders.
The manifestations of a learning difficulty can change overdevelopment. What appears to be mild at one age can become asignificant problem in another life stage.

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Literacy
The ability to derive andcommunicate knowledge
and meaning from written
language.

Many people suffer fromdyslexia. Albert Einstein,Harrison Ford and George
Washington are said to have
had the condition

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IACAPAP Textbook of Child and Adolescent Mental Health

DEFINITION AND CLASSIFICATION
For many years, the most popular approach to identifying specific learning
difficulties (SLDs) was to use discrepancy criteria – that is, to identify a child as
having an SLD if their attainment was below that to be expected based on general
cognitive ability. Indeed, the two main classification systems used in clinicalpractice at the time of writing – ICD-10 (World Health Organization) and DSMIV (American Psychiatric Association) – follow the discrepancy model to classify
children with learning difficulties. However, the use of the discrepancy approachin educational settings has gradually declined because there is little evidence ofdifferences in etiology or prognosis for children with SLDs who have higher orlower IQ (Snowling, 2008). Accordingly, the proposal for DSM-5, which wewill discuss below, moves away from this approach. An alternative approach toclassification, known as the response to intervention approach, is gaining interest andbecause there are merits in this approach for low and middle income countries, itwill also be considered.
The diagnostic systems differ in their approach to the identification of SLDs(see Table C.3.1). When compared to ICD-10, DSM-IV is less explicit about
the extent of delay that must be recorded before a diagnosis is considered, andin DSM-5 it is proposed that the discrepancy formula be abandoned altogether.
Diagnostic systems also differ in their treatment of co-morbidities. In DSMIV and DSM-5, co-occurring difficulties receive parallel diagnoses. In ICD-10
co-occurring difficulties are placed on a hierarchy with the diagnosis pegged to
one nodal difficulty or cluster of difficulties. Sometimes the status given to aco-occurring difficulty has implications for understanding the etiology of the
difficulty (e.g., literacy difficulties and language difficulties occurring in parallel, or
one following from the other).
All these diagnostic systems are fashioned after medical models and there
is sometimes a mismatch between clinical diagnosis and the labels for various
learning-related difficulties commonly used in educational settings. Below are
examples of clinical diagnoses that do not easily fit into what is seen in regularclassrooms:•

Specific difficulties with spelling. Poor spelling usually co-occurs withdifficulties in reading, but in some writing systems (where reading
is regular but spelling-sound mappings are inconsistent), spellingdifficulties are more common than reading difficulties•

Disorder of written expression. There is an under-diagnosis of thisdisorder. This is not so much because poor written expression skills are
difficult to identify but because written expression is seen as following on
from a more fundamental difficulty with reading and spelling.

For a discussion about
issues surroundingclassification see: Changing
concepts of dyslexia:
nature, treatment and comorbidity, November 2009;
Journal of Child Psychology
and Psychiatry Virtual Issue
on-linePhonemes/
phonological skills
Phonemes are thesmallest sound units
in a language that arecapable of conveying a
distinct meaning (i.e.,the m in mat or b in bat).
Phonological skills concern
an individual’s ability toidentify, categorize ormanipulate these sounds,
and include skills such as
segmentation, blending,rhyming, and alliteration.

In addition, some diagnostic labels are umbrella terms and therefore
uninformative for intervention. For example, both DSM-IV and ICD-10 classify
together reading comprehension difficulties and reading accuracy difficulties.
However, these are disorders which require different interventions: whereasinterventions for reading comprehension focus on developing broader oral
language and inferential skills, interventions for reading accuracy primarily target
phonological skills.

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Specific learning difficulties

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Conservative about extent of distance
between age/intelligence and attainments
for making a diagnosis

On individually administered tests,
differences in child’s performance mustbe two or more standard errors below
prediction based on age and general
intelligence

The lowered attainment must not be
attributable to poor opportunity for qualified
literacy instruction or other external factors
such as disrupted schooling and recent
entry into regular schooling

Difficulties must be evident from the earliest
stages of acquisition of the particular skill.
This criterion is suggestive of abnormality infoundational cognitive skills and indicative ofa difficulty that may have a biological basis
rather than a socio-cultural/environmental
basis.

••••*Expected publication date is May, 2013.

Disorders include reading disorders (81.0),
spelling disorders (81.1), disorders ofarithmetic skills (81.2) and mixed disorder ofscholastic skills (81.3)•

ICD-10
Disorders include developmental reading disorder(315.00), mathematics disorder (315.1) and disorderof written expression (315.2)
The child’s extent of learning must be substantiallybelow that of peers who have received equivalent
opportunity
The lower levels of achievement must be seen to
be interfering with academic achievement and dailylivingWhen a known sensory deficit such as nystagmus
or low vision accompanies the underachievement,
the extent of learning delay should be far in excessof the known contribution of the sensory deficit. The
co-occurring difficulty must also be coded
All co-morbidities should be recorded suchas attention deficits, emotional difficulties andbehavioral disorders
Other associated social-emotional difficulties are
known to occur including reduced self-esteem
and self-efficacy for academic performance, andincreased barriers for entry into school and postschool training as well as in the world of work.
DSM-IV encourages that this and similar otherassociated difficulties be recorded.

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DSM-IV•TABLE C.3.1 Approaches to classification

Learning disorder is the generic term to describe disorders
characterized by difficulties in learning academic skills –accurate and fluent reading, writing and arithmetic – whichsignificantly affect academic achievement or daily functioning if
accommodations are not madeLearning disorders are grouped together with communication
disorders (as neurodevelopmental disorders) to reflect their onset
during the pre-school or early school years
Learning disorders described in DSM-5 are dyslexia, dyscalculia
and disorder of written expression
DSM-5 proposes to drop the discrepancy criterion. For the firsttime reading fluency will be recognized as an area of assessment
for diagnosis (earlier manuals only mentioned reading accuracy).
This change reflects the current understanding of the clinicalpicture of dyslexia – poor reading fluency is known to be a
persistent problem into adulthood in most languages, and poor
reading fluency (rather than reading accuracy) is a defining
feature of dyslexia in many languages
Specific difficulties with reading comprehension (previouslyclassified within reading disorder) will not be clearly accountedfor. Thus, diagnosis for two categories of children remains
unclear: (i) those with exceptional decoding skills but poor
reading comprehension, and (ii) those who begin with poor oral
language and go on to have poor reading comprehension. The
poor comprehender profile is noted as a feature of language
impairment and perhaps will be classified in a new category
called learning disability.

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Proposed for DSM-5*

IACAPAP Textbook of Child and Adolescent Mental Health4IACAPAP Textbook of Child and Adolescent Mental HealthDiscrepancy criteria qualified by local conditions
For most childhood and adolescent disorders the process of arriving at adiagnosis must be sensitive to local culture and ways of living. Such sensitivity
is critical for SLDs since many different factors affect the learning of basic skills,
particularly literacy. For example, some children learn to read in their homelanguage, others in a neighborhood language or a language imposed by sociopolitical forces, yet others achieve literacy in an entirely foreign language, having
heard very little of the language at home, in the community and sometimes even inschool. In other instances, children may learn to read in two or three languages,
and become bi-scriptal or multi-scriptal. Learning how to read and write these
multiple languages may happen simultaneously or sequentially, with children
being introduced to additional languages at different stages in their school career.
Any understanding of the specific literacy difficulties needs to be sensitive to themultiple pathways to literacy.
A strong relationship also exists between socio-economic conditions andliteracy outcomes. In a survey of 672 high school children in the UK tested during
the standardization of the York Assessment of Reading and Comprehension, a clear
association was found between reading ability and social deprivation. The survey
used the postal codes of children’s homes to rank them for social deprivation. A
lower rank was for localities (postal codes) in which children experienced many
forms of deprivation relative to the UK norm. The trends in the data are presented
in Figure C.3.1. About 33% of children in the deprived neighborhoods were poor
readers, close to double when compared to the more advantaged neighborhoods,
where between 5% and 18% of children were classified as poor readers.

Reading fluency
The ability to read quickly,
accurately and effortlessly,
with appropriate expression
and meaning.
Reading accuracy
The ability to correctly
decode the written
language, especially whenreading aloud.
Readingcomprehension
Knowledge andunderstanding derived fromtext.
Reading attainment
Level of achievement in any
or all reading skills, usuallyestimated by performanceon a test.

Figure C.3.1 Reading ability is modulated by local conditions(SWRT = single word reading; Comp = reading comprehension, SS =standard score)

Reading ability and social deprivation (n=672)
100%
90%
80%
70%
60%
50%
40%
30%
20%
10%
0%

7.0%

60.1%

32.9%

8.0%

67.2%

24.8%

10.0%

23.8%

71.9%

65.9%

18.1%

10.3%

23.1%

71.4%

High

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Bi-scriptal, multiscriptal
The ability to read or write
the scripts of two (bilingual)or more languages.

5.5%

Rank 1&2 Rank 3&4 Rank 5&6 Rank 7&8 Rank9&10

Social deprivation

Goo d Readers
AdequateReaders
Poo rReaders

Good Readers:
SWRT & Comp SS 110+
Poor Readers:
SWRT &/or Comp SS<85Low

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IACAPAP Textbook of Child and Adolescent Mental Health

The influence of social deprivation on literacy attainments is also foundamong children gaining literacy in a second language although, similar to monolingual groups, the impact appears to be uneven across cognitive domains. The
annual surveys of the Uganda National Education Board, for example, documented
better language and literacy attainments in the relatively more advantaged localities
in the capital city of Kampala and the surrounding urban area than in moredeprived rural areas (NAPE, 1999-2008), while a pre-school survey of SpanishEnglish bilinguals in the US (Bohman et al, 2010) showed vocabulary learning to
be more vulnerable to the influences of social deprivation than acquisition of basic
grammar.
The discrepancy formula, which is favored by ICD-10 and DSM-IV but not
DSM-5, is particularly difficult to apply when there is variable opportunity andthe literacy environment leaves children far behind in their attainments. In suchsituations, the learning difficulties and low level attainments mimic the difficulties
and skills profile seen among children with dyslexia. For example, when large
numbers of children in a class are below the expected level for their grade and age,
not all the underachievers will show a cognitive profile that is typical of dyslexia.
Such children may be said to show a dyslexia-like picture but are certainly not eligible
for a clinical diagnosis. Clarity about the distinction between the disorder andenvironmentally induced underachievement, that mimics the disorder, is essential.
Without such a distinction there will be an over-diagnosis of the disorder and an
unacceptable use of a deficit/disorder perspective for all interventions.

Dyslexia
A developmental disorderaffecting the skills involvedin the reading and spellingof words, in the absence of
any intellectual impairment.
Symptoms range from mild
to severe, and various
subtypes have been
proposed.

In many countries there are no locally standardized tests. In such contexts,
test results can be difficult to interpret and there is a genuine concern that test
findings can mislead. In other words, test results in the absence of normative data
are an unreliable metric for deciding who has a learning difficulty and who is freeof learning problems.
The discrepancy formula is problematic on several other fronts as well.
For example, a formula using a child’s age and predicted attainment for that age
assumes a mono-grade classroom, with a pre-specified age band in each class. But
in many communities the age-grade arrangement is quite different. Schools may
be multi-grade with children from several grades in one class. In such schools
learning targets may not follow a year-wise framework. Sometimes, the age criteria
for school admission may be flexible with older children entering lower classes.
The discrepancy index between intelligence and attainment has also turned
out to be problematic. The assumption here is that a higher IQ is associatedwith better reading scores, and when this is not the case then it is an indicationof a learning difficulty. Evidence is now available from several large scale studies
that the correlation between IQ and reading skill is modest, thus the simple
intelligence-reading attainment discrepancy formula is not very useful and it isunclear what exactly a discrepancy index based on IQ can say about the nature ofa learning difficulty.
Given all the above, the criteria used for “diagnosis” must be agreed
within the context of the local educational setting. Such sensitivity can correct
the mainly acultural nature of descriptions in diagnostic systems. It can ensurethat there is a clear distinction made between learning difficulties attributable topoverty, deprivation and insufficiency of school-related experiences, and learning

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IACAPAP Textbook of Child and Adolescent Mental Healthdifficulties that follow from biologically-based cognitive deficits. But, even after
we have smoothed out the jagged edges of our definitions and created a diagnostic
system that is contextually appropriate, there remains one further difficulty withthis approach – it is not grounded in educational practice and instruction. A
diagnosis does not in itself indicate what may be the best way to intervene to help
the child. Moreover, the diagnosis gives no indication of the cognitive deficits that
underpin the disorder, nor does it highlight potential risk factors. Some of theseconcerns are addressed in the next section.
Response to intervention as an approach to diagnosis
In this approach to classification, children are said to have a specific learning
difficulty if they continue to struggle even after substantial individualized help has
been given, and this is documented through a continuous monitoring of their
response to the intervention. The term individualized help means any teaching
program motivated by the child’s specific learning needs. The individualizing of
the program can be at the level of worksheets, teaching targets, time given to thechild to finish an assignment and the ways in which the assignment is assessed.
Individualized help may be through a mainstream program that is suitably adapted(the child remains in class and is given what everyone else is receiving but withsome changes). Alternatively, the individualized program may be offered throughremedial teaching in small groups or on a one-to-one basis. The term continuous
monitoring means that there is a predetermined time plan for repeated evaluationof the child’s skills and attainments. This could be at the end of every school termor every academic year or at any other natural transition point in the school system.
The scope of what is monitored is also flexible. The areas can cover foundation
skills for learning as well as the main curriculum areas that are important for thechild to show improvement in school.
The response to intervention approach recommends a postponement of
diagnosis till after a proven intervention has been offered to the child. School
under-achievement is a serious possibility for many children, not least becauseof poor quality teaching and long gaps in teaching input. An essential first stepin such contexts is to defer the diagnosis and first arrange for a period of focusedteaching support. The essential ingredients of such an approach are laid out in a
recent report to the UK government (The Rose Review; 2009).
Models for response to intervention depend on how many layers of support
are made available to the child. Each layer of support may be referred to as a“tier” or a “wave”. Figure C.3.2 below summarizes three responses to intervention
models.
One concern about the response to intervention approach is that it isexpensive. Another concern is whether the intervention on offer is indeed the best
suited for the child. This is mainly because any intervention, by its very attempt
to be focused and specific in its targets, may inadvertently neglect an important
domain that needs remediation and skill-building. Thus, an intervention may befocused on reading-related skills while neglecting other skills such as language. If
a child has a primary language difficulty, information gained from response to areading intervention may be misleading. The intervention may simply not haveaddressed the skills the particular child lacked. Further, core curricular areas suchas handwriting, math and expressive writing are often prone to neglect.

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Expressive writing
Writing which explores
the personal feelings,
experiences and opinionsof the writer.

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Figure C.3.2

Models that allow for assessment of Response to Intervention

Single-tier model: all children receive a fairly long quality program and then assessment is conducted.

Two-tier model: children receive a second intervention if they still struggle some time after a first module.

Three-tier model: children who are below expected level at each tier receive a progressively more intensive
remedial program.

Summary
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School underachievement is often the reason for referral to child and adolescentclinics and allied settings. School underachievement is a visible feature for anumber of different underlying difficulties.
A diagnosis of one of the specific learning difficulties is heavily dependent on
the educational, socio-economic and socio-cultural context.
Popular approaches to diagnosis use discrepancy criteria – discrepancy isassessed between a child’s age/grade/IQ-expected and actual performance ona specified learning task.
Such a discrepancy formula is neither informative for intervention nor a
description of underlying causes for the difficulty.
An alternative approach to identification is to allow the child to first receive
quality teaching (quality-first) which can assure the assessor that the symptom
picture is not because of lack of opportunity. Following the intervention,
those children who remain behind are the ones who qualify for a diagnosis.
However, the response-to-intervention approach can be misleading if theintervention itself is of poor quality or the area of intervention is other than
the specific difficulty of an individual child. In such instances measuring
response-to-intervention is a futile exercise.

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IACAPAP Textbook of Child and Adolescent Mental Health

LITERACY LEARNING
Literacy learning is directly dependent on the writing system that a child istaught. Figure C.3.3 shows a map locating some of the scripts in which children
are learning to be literate across the world. The map covers the Latin-derived
scripts like English, German and French, the Cyrillic scripts of languages like
Russian and Ukrainian, the alphabet systems of Arabic and Hebrew, the Asian
scripts of Hindi, Bengali and Tamil, the mixed scripts of Japanese and Korean, theChinese scripts of Hong Kong, Taiwan and other varieties on mainland China, thesyllabaries of the native American languages and the abugida of Ethiopia. This list
is by no means exhaustive (for example, some children are learning through thetactile modality – Braille), but underlines the sheer diversity in scripts and how
easy it is to overlook the fact that understanding how specific learning difficulties
impact literacy requires an understanding of the writing system of a region. In
the following section, we discuss three aspects of writing systems: the directionof writing, the number of symbols in the writing system and the level of spoken
language that is encoded in the symbols of the writing system.
Some defining features of writing systems
Writing direction is the reading direction
Modern day writing mostly lays out the symbols left to right (e.g., Bengali,
English, German and Tamil), right to left (e.g., Arabic, Divehi, Hebrew and Urdu)
or top-down (some forms of Chinese and Japanese). But there are several othersymbol arrangements that are possible and that have been used successfully by
literate societies down the centuries. Figure C.3.4 below gives two examples ofsymbol arrangements, no longer in use, but used by large communities for several
centuries. Literacy instruction for these ancient writing systems would have perhaps
focused on ensuring that learners understand the logic of the writing direction.

Figure C.3.3

A selection of scripts in which children gain literacy

Source: Wikipedia GNU free documentation license.

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Figure C.3.4
Hieroglyphic.

Writing direction in the ancient scripts of early Greek and Egyptian

One can only speculate on what the clinical picture of a specific literacy difficulty
might have been in these contexts!
Writing systems have a symbol register
The symbol units in English, French and Italian are called letters, the Bengali,
Hindi and Tamil symbols are called akshara and the Chinese symbols, characters.
The symbol sets in each of these and other systems have unique contours and visualfeatures that distinguish them from others.
The number of symbols in a writing system can be as little as in the 20s
to as many as 2500 or more. We refer to the small symbol registers as contained
orthographies and those with hundreds of symbols as extensive orthographies. The
European languages for example have symbol sets of less than 35 and are examples
of contained systems. The Asian alphasyllabaries, with 300+ symbols, and theChinese systems, with 2000+ symbols, are extensive systems. The pace of learning
the different number of symbols varies as a consequence. Among contained
systems, children quickly master the basic symbol set, typically within one school
year. Among the extensive systems, new symbols continue to be learnt in middle
and high school, and beyond. Any attempt at making comparisons about symbol
learning across the two types of writing systems is therefore not straightforward.
And, as can be expected, when symbol learning demands are different, there isa knock on effect on how word reading, spelling, reading comprehension andexpressive writing are developed within each system.

Click on the picture to accessa website with a fascinatingcollection of scripts down theages.

The differences between contained and extensive orthographies have anotheroutcome that is of direct interest to understanding children who fall behind inliteracy. In the extensive systems, because new symbol learning takes place overa protracted period of time, children vary in their level of symbol knowledge in
middle school and even high school. Symbol knowledge thus becomes a robust
concurrent predictor of individual differences in literacy development (for Indian
akshara systems: Nag, 2007; for Chinese: Tong et al, 2010). Children who
begin with lesser symbol knowledge are less accurate in reading words correctly
and quickly (reading accuracy and reading speed). In the contained systems
however, knowledge about the small number of symbols is easily gained by all
children. Individual variations in letter knowledge disappear after an exceptionallyshort time, often confined to the first year of literacy instruction. Thus symbol

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IACAPAP Textbook of Child and Adolescent Mental Healthknowledge (or letter knowledge) is a useful concurrent index for understanding
individual differences in literacy attainments only within the first few years ofprimary school. Nonetheless, symbol knowledge is a good longitudinal predictorof literacy attainments in both contained and extensive orthographies; children
who are slow to learn the symbols of their language often remain slow in literacy
development in the following years.
Writing systems represent sounds
A primary function of written language is to capture the words andmeanings of the spoken language. However, writing systems vary in the level atwhich the symbol units capture spoken language. Below are four examples ofdiffering levels of representation.
••

The alphabet captures sound at the level of small sub-syllabic sound units
called phonemes. English is an example of an alphabetic writing system.
The sound /p/ for example is represented by the letter “p” (“pin”, “pot” and“picture”) and the sound /s/ by the letters “s” and “c” (“sun” and “sign”, “cell”
and “center”). In the alphabetic systems, there is thus a correspondence
between the symbols (letters or graphemes) and phonemic sounds. Several
European languages including Dutch, Finnish, Greek, Icelandic, Norwegianand Spanish, use letters to represent phonemes. Other examples of alphabetic
scripts are Hebrew, Arabic and Cyrillic.
The alphasyllabary is another type of writing system. Alphasyllabic scripts
have a dual representation; their symbols stand for syllable-level sounds suchas /ka/ and /ko/ but can be further segmented to reveal the phonemic soundcomponents (called phonemic markers). Thus an alphasyllabic symbol
such as /ko/ can be pulled apart to represent which segment of the symbol
represents the /k/ and which part the /o/. Several alphasyllabic writing
systems are concentrated in and around the South and South East Asia
region. These are Indic scripts that have their roots in the ancient Brahmi
writing system, and some examples are Bengali, Gujarati, Hindi, Tamil, Thaiand Sinhala. Other examples of alphasyllabaries are the abugida of Ethiopia
and neighboring regions of North Africa, and the writing systems found in
the northernmost parts of North America.

•

In the syllabary, another closely similar writing system, the symbols map onto
sounds only at the level of the syllable. The syllabaries are distinguishable
from alphasyllabic symbols because they cannot be de-constructed visually
below the level of the syllable to reveal smaller sound-bearing features.
Examples of syllabaries are the Cherokee script and the Japanese hiragana.

•The character is the symbol unit of the Chinese writing systems, and iscommonly called a logograph. The characters represent abstract ideas. They
carry specific lexical information, often representing meaningful units of
the language called morphemes. Thus, the symbols of the Chinese systems
are meaning-bearing units rather than merely notations of the sounds of alanguage, as in the alphabetic, alphasyllabic and syllabic systems describedabove. Chinese characters, however, have distinct visual features calledphonetic radicals which give clues to the sounds that the symbols represent.
In other words, the characters of Chinese carry both lexical and phonologicalinformation and thus the writing system is more appropriately called asemanto-phonetic or morpho-phonemic.

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Alphabetic systems
Writing systems in which
letters, symbols or signs,
usually arranged in a fixedorder, are used to represent
one or more phonemes in
the language transcribed.
Alphasyllabic
systems
Writing systems in which
symbols and signs
represent sounds at thelevel of both the syllable
and the phoneme.
Chinese systems
Logographic writing
systems, in which complex
signs or characters areused to represent words ormorphemes in the Chinese
languages.

Contained
and extensive
orthographies
Contained orthographies
are writing systems inwhich a relatively small
number of symbols areused to represent sounds
throughout the language(i.e. alphabetic systems,
spanning around 24-36
letters). By contrast,
extensive orthographies
are writing systems inwhich a vast number ofsymbols or characters areused to represent sounds
throughout the language(i.e., alphasyllabic systems;
the Chinese system –spanning over 2,500
characters).

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The cognitive processes that underpin literacy learning in each of the four
writing systems described above are subtly different. But there is also growing
research evidence to show that there are some commonalities involved in thefoundation skills required for learning to read across writing systems. We turnnext to describe these skills, as well as to highlight some script-specific cognitive
demands.
The foundations for learning to read
Oral language skills are critical for the development of literacy. Teachers
are often told that it is vital they trust the adage “speaking and listening help
reading and writing”. This is exceptionally sound advice that has been borne out
by literacy research. Children who have better language proficiency in the languageof reading instruction are at an advantage. They have more language tools for thetask of understanding the written material. Oral language supports several aspectsof literacy including decoding words, making meaning of texts, and expressive
writing. There is also evidence to show that when teaching specifically focuses on
improving oral language, the gains are twofold: children get better at multiple
skills associated with oral language and they show improvement in their literacy
skills.
Oral language is an overarching term for several skill domains, namely
phonology, semantics, syntax and pragmatics. Phonology refers to the speech soundsystem and how it maps to meaning, semantics refers to the meaning relationships
between words (how our vocabulary knowledge is structured), grammar to theformal structure of the language (syntax and morphology) and pragmatics to the useof various cues which make communication meaningful (e.g., use of information,
intonation, emphasis and gesture). Each of these skills supports the developmentof literacy but, among them, phonology has been a lead candidate for defining
the core deficit in specific reading difficulties/dyslexia. In this section we discusssemantics, grammar and pragmatics under the umbrella term broader oral language
skills. We then proceed to examine the role of phonology in more detail.
Broader oral language skills support literacy in various ways, and there isevidence that better oral language skills are associated with better performance on
specific sub-components of literacy. It is important to note that we are discussing
here the oral language skills that are specifically in the language in which literacy is
being taught. When the literacy language is the child’s less proficient language thenthe child may lack these vital strategies.
Word recognition•

Exception words are words that do not show predictable symbol-soundassociations. Examples of exception words in English are ‘knife’ with a silent‘k’ and ‘whistle’ with an unusual letter string for the ending sounds. A
straightforward decoding strategy cannot suffice and word recognition draws
upon broader oral language skills. The role of semantics and syntax (together
affording a linguistic context) in learning exception words has been shown inseveral languages.

•

Polymorphemic words are words with more than one meaning unit yoked
together. Broader oral language skills help decode polymorphemic words
probably because better oral language allows children to “see” the embedded
morphemic units more readily. Examples of polymorphemic words are

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Click on the picture to access“Developing Early Literacy:
Report of the National Early
Literacy Panel”

Morphology
The study of the structure
and content of a given
language’s word forms andlinguistic units.
Pragmatics
The study of the useof language in social
contexts and the ways inwhich people produce andcomprehend meanings
through language.
Semantics
The study of meaning inlanguage.
SyntaxThe study of the rules
governing the ways inwhich words combine toform phrases, clauses, andsentences (i.e., grammar).

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IACAPAP Textbook of Child and Adolescent Mental Healthcompound words like butterfly, sunshine and somewhat, words with prefixes
like un-conscious, non-sense and poly-morphemic and words with suffixes likecomb-ing, amuse-ment and electri-cian. A language where lexical compounding
is frequent is Chinese. An example of Chinese word formation throughcompounding is the three character word for giraffe (chang2.jing3.lu4) which
represents the three morphemes long.neck.deer (Chenet al, 2009). We now
have good evidence to show that those children who have insights into theinternal morphemic structure of Chinese words are better at word reading.
•Some languages are densely inflected using many varieties of grammaticalmarkers to communicate meaning. Inflections include case markers andperson-number-gender markers which are either attached or closely associatedwith specific nouns, verbs and other grammatical units in sentences. In
these languages, knowledge of inflections (inflectional morphology) helps
to predict upcoming information in sentences and thus may facilitate word
decoding. Examples of inflections in English are the past tense inflection –ed(test- tested) and the plural inflection –s (result-results).

•

In some languages such as Japanese, the same symbols may change in soundvalue depending on whether it is a single character word or part of a multicharacter word. Thus, the same symbol (called kanji) is the first symbol inflower and in pollen, but they each have a different pronunciation: /hana/and /kafun/ (Wydell, 2003). The underlying rule for choice of sound has to
do with whether the word is a native Japanese word (called Kun-reading) ora loan word from Chinese (called On-reading). Such changes in symbolsound correspondences based on the native-foreign roots of words are seen inother languages as well, such as Tamil and Bengali, and the role of vocabularyknowledge is thus essential to decode the word.

•

In some languages such as Arabic, texts for skilled readers do not represent
the vowels (unvowelised writing). It is therefore the sentence context andbroader oral language skills that allows the reader to recognize the word.
Indeed, knowledge of morpho-syntax is crucial for reading because whenvowel units are left unrepresented in the writing, a given consonant string canstand for any number of words.

Click on the picture toaccess a website (Readingfor Meaning) with activity
ideas for an oral language
program.

Children's artwork in Arabic,preschool in Indonesia.
(Picture: S. Nag).

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IACAPAP Textbook of Child and Adolescent Mental Health•In some languages, words with multiple morphemes undergo subtle
phonological changes particularly at the point where the morphemes join.
In English the suffix -tion can cause phonological changes at the boundary– connect to connection, separate to separation. Knowledge of these morphophonemic aspects of internal boundaries of words can help decoding.

•Broader oral language skills can help to recognize a word that is proving
difficult to decipher using a straightforward phonological decoding strategy.
They are particularly used for reading less transparent words, words withmultiple meaningful units and lesser known words, for example for learners
in a non-dominant language.

Spelling•

In some languages, broader oral language skills (especially morphologicalknowledge) can help in deciphering the spelling of a word. Thus in English,knowing that drama and dramatist are morphologically related words, can help
spelling them. Examples of other words in English, for which derivationalrules make spelling simpler, are words with suffixes –ment (involvement), –ness (wetness), –ion (connection). Morphemic rules are used in word spellingin several other languages including Dutch, Kannada and Arabic.

•

In some languages, different word forms are homophones (words with same
sound but different spelling). It is only knowledge of how morphology maps
to the written form of the word (meaning-symbol linkages) that can assure
correct spelling. In French for example, conjugations of the verb manger (eat)are pronounced in the same manner even though they have different spellings:
je mange (I eat); tu manges (you eat); ils mangent (they eat). In Cantonese, thesyllable /fu/ is written with a different character depending on its tonal value:/fu1/ (skin), /fu2/ (tiger), /fu3/ (trousers), /fu4/ (symbol), /fu5/ (woman) and/fu6/ (father) (Tong et al, 2010).

•

Morphological knowledge has been found to be particularly useful inlanguages such as Arabic, Japanese and Bengali where phonological valuesof symbols change depending on context. In Bengali for example, word
medial consonant clusters are realized in spoken form quite differently fromthe written spelling - the word podda (lotus) is written as padma and sotto(truth) as satya. Knowing the rule that consonants in word medial positions,even if geminated in spoken form, will be a mixed cluster, however implicit thisknowledge may be, helps in spelling these words.

•

The use of morphological knowledge to read symbols is particularly importantin morpho-phonetic writing systems like Cantonese and Mandarin. This isbecause the same tonal syllable in different polysyllabic words can be writtenwith a different character. Take the Cantonese syllable /laan4/. It has adifferent spelling (character form) when it represents different meanings suchas block, column, orchid, waning and wave (Tong et al, 2010).

•

Some words carry unusual internal phonemic changes making spelling thesewords as demanding a task as reading them. Once again, morpho-phonemic
knowledge about word internal boundaries helps in the decoding of suchwords.

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Chinese is an example of an
extensive orthography.

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IACAPAP Textbook of Child and Adolescent Mental Health

Reading comprehension•

Reading comprehension is closely linked with listening comprehension;
therefore, children with better oral language skills are better at reading
comprehension. Broader oral language skills help extract context-related
information. Both context and word-level meanings combine to support
comprehension of the written text.

•

Individual words may carry both meaning and grammar-related information(morpho-syntactic information). In such instances, greater awareness of theroots and inflected markers for various grammatical functions has been foundto be associated with better reading comprehension. In Kannada, a languageof South India, the phrase biijagaLu nungidanu (swallowed seeds) comprises
the following morphemic units: biija (noun + plural) nungu (verb + past,masculine, singular, 3rd person).

•

Sentence processing depends quite critically on the mechanism of prediction.
When children have a better idea of sentence structures they are better able
to comprehend what they read. Better knowledge of syntax and grammar
can therefore help to more accurately predict, and thus more quickly
recognize, upcoming words in a sentence. For example in English, when
there is an accurate interpretation of the word order, reading comprehension
is supported.

Each of these interactions between broader oral language and the subcomponents of literacy are critical right from the outset of literacy and are likely
to affect literacy learning into adulthood. For example, findings from a survey ofclose to 40,000 households in the US found that young adults between the agesof 21 and 25 years who struggled with reading comprehension were also poor in
spoken language tasks.
Mappings between cognitive domains support literacy development
The process of learning to read entails becoming skilled at mapping thesymbols of the writing system (orthography) on to the sounds that they represent
in the language (phonology). In addition, written words and sentences need to bemapped on to meanings (semantics). The schematic drawing in Figure C.3.5 is a
simple illustration of how the three cognitive domains interact. Skilled reading,spelling and expressive writing require that connections across the domains areaccurate and efficiently executed. For example, the process of decoding words
commonly requires linkages to be made between orthography and phonology:
from symbols to sounds for reading, and sound to symbols for spelling. But inmany languages, such as Arabic, Bengali, Chinese, English and Tamil, the same
symbol may have different sounds depending on the context in which it appears.
In such cases, decoding additionally requires making links between orthography
and semantics+grammar. These different types of links across multiple domains are
the “glue” that hold written and spoken language together.
Mappings between phonology and orthography
The linkages between phonology and orthography are more or lesspredictable in different writing systems. For example, if we take the letter string“tea”, in English it means a hot beverage and the written word maps on to the
spoken syllable /te/. In Finnish, the same letter string “tea” is a name, and issounded out exactly as it is written, making it a two syllable word /te/+/a/. The

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Transparent writing
systemA writing system in which
only one letter (or symbol)
is used for each phoneme(e.g., Finnish).
Opaque writing
systemA writing system in which
single letters (or symbols)
can represent multiple
phonemes (e.g., different
vowel sounds in the English
language), or where asingle phoneme can be
represented by multiple
letters (i.e., c and k in the
English language).

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IACAPAP Textbook of Child and Adolescent Mental Health

Figure C.3.5

A schematic representation of three cognitive domains involved in literacy.

difference between English and Finnish is one of “transparency”, which refers tothat feature of writings systems “where it is approximately true that individual
letters correspond reliably to individual sounds” (Seymour, 2005 p299). Finnish isa transparent language whereas English is an opaque language. Other examples oftransparent languages are Italian, Serbian, Kannada and Divehi, while examples ofmore opaque languages are Bengali, Danish, Portuguese and Urdu.
We now know that when the mappings are regular, consistent and hencetransparent, children learn to read faster. One of the biggest cross-linguistic studies
to confirm this was initiated by a network of European researchers, the COST A8
Consortium (1995-1999). The COST A8 Consortium assessed children in grade
1, who were under what the authors called “standard teaching conditions” for theparticular country (Seymour, 2005). Children were asked to read aloud lists ofwords and non-words (letter strings that are not meaningful). While decoding ofwords can draw upon both sound-symbol linkages as well as semantic knowledge,
reading of non-words cannot draw upon meaning or context related strategies,
and is thus often considered a pure indicator of phonological decoding skills,
requiring detailed knowledge of what sounds the individual letters map on to.
The comparison across countries confirmed the advantage that transparency of awriting system brings to the process of learning to read. In the more transparent
languages, children in grade 1 were already accurate more than 90% of the time
when decoding words. On non-words too these children were high in theiraccuracy, reading more than 80% of items on the list correctly. The exception was
English, where the inconsistency of the mappings slowed down children’s masteryof decoding skills. Their accuracy rates fell to below 40%.

Decoding skills
Skills necessary to analyze
and correctly interpretthe graphic symbols of afamiliar language (e.g., theability to connect a printed
word to the spoken word it
represents).

The languages compared by the COST A8 Consortium were all contained
orthographies with symbol sets between 24 and 32 symbols. Similar effects oftransparency on reading accuracy are also seen in the extensive orthographies.
In a comparison of adult Hindi-Urdu bilinguals for example, reading was faster

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IACAPAP Textbook of Child and Adolescent Mental Healthand better in Hindi (more transparent) than Urdu (less transparent) (Rao et al,2011). In another comparison between two Japanese scripts, a similar difference
was found between the more transparent Hiragana and the less transparent Kanji(Chen et al, 2007).
There are a number of possible explanations for the differences in speed andaccuracy observed across writing systems:•

Transparent writing systems allow for ease of assembling sounds because once
the individual symbols are decoded in these systems, a mere assembly of thesounds will reveal the word. The less transparent systems on the other handneed other layers of knowledge to work out the word. The phonologicalassembly route to decoding and the route via other layers (usually lexical)
broadly differentiate the more and less transparent systems.

•

The processes involved in learning about the mappings between symbols andsounds differ. This is a slightly different learning challenge from the endprocesses that support decoding outlined above. Transparent systems have astraight forward mapping which allows for faster grasp of the symbol-soundlinkages. This is essentially statistical association learning between visualand verbal codes. Less transparent systems require many more instances of
exposure to learn the variations in the system. In other words, it is easier tolearn that the sound of “p” is always /p/ (transparent) than to learn that thesound /ai/ may be represented though /i/, /eigh/, /ai/ or /aye/ (not transparent).

The role of phonology in literacy learning
Phonological processing skills refer to knowledge about the sounds of alanguage and the skill to manipulate these sounds. An example of a phonologicalskill is the ability to drop the first sound in words like “meat” and “shut” (to get“eat” and “ut”), or the skill to replace their first sounds with “l” (thus “leat” and“lut”). There is good evidence from across languages and different age groups
that learning to read continuously draw upon such phonological skills. In turn,developing reading skills re-shapes phonological skills. Awareness of phonemes,for example, is a robust predictor of single-word reading attainment in severalalphabetic and alphasyllabic languages – for example, English (Muter et al,2004), Arabic (Abu-Rabia et al, 2003) and Kannada (Nag, 2007). Importantly,
difficulties with phonological skills are a defining characteristic of many poor
readers, in different types of writing systems and languages and across age groups
into adulthood.
What is the reason for such a close associations between phonology andliteracy? First, writing systems directly represent phonology and hence learning
to read immediately draws upon this cognitive domain. Second, in the process ofreading, the segmental units in spoken sounds become better represented because
the symbols are visual representations of phonological units. However, the level atwhich the specification occurs varies across writing systems because, as discussed
above, writing systems differ in the level of spoken language they represent:•

For alphabetic systems, the specification is at the level of the phoneme.

•

For alphasyllabic systems, the specification begins with the syllable andmoves onto the phoneme.

•

For Chinese systems, the specifications are mainly at the level of the syllable.

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IACAPAP Textbook of Child and Adolescent Mental Health

Visuo-motor skills and visual processing skills
These are two areas that have not been included in the schematic diagramin Figure C.3 5. There is, however, reason to believe that both of these skills areimportant foundation skills in the visuo-spatially complex writing systems suchas the Japanese kanji, the Chinese systems and perhaps also some of the Indianalphasyllabaries. Research in this area is ongoing but initial data from both crosssectional as well as longitudinal studies suggests that visuo-motor skills and visual
processing skills are associated with individual differences in reading skills (Nag& Snowling, 2010; Tong et al, 2010; McBride-Chang et al, 2005; Wydell, 2003).
Summary•

Typical literacy development draws upon multiple cognitive domains. Of
these, phonology, vocabulary and syntax, as well as the skill for mapping
efficiently between visual and verbal codes, are the best researched foundation
skills for literacy development•

When the symbol system is visuo-spatially complex, visual processing skills
appear to be important predictors of early literacy attainments•

Children are learning to be literate in a variety of orthographies and thesewriting systems differ on several counts including the number of symbols
they carry and the level at which they represent spoken language. The
cognitive demands of learning to be literate are therefore subtly different ineach writing system•

However, behind the script-specific details are some common cognitive
processes that are essential for literacy learning in all writing systems. Thesecritical foundations include oral language skills and skilled mapping between
sounds and symbols.

Table C.3.2 opposite lists the broadly similar foundation skills acrosswriting systems, but note the specificities of each of the typologically very different
systems.

School, Maputo,
Mozambique.
Photo: Peter Reid

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Specific learning difficulties

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Knowledge of homophones, structureof polymorphemic words and rules oflexical compounding
Knowledge of acceptable word order

Knowledge of derivational
morphology, morpho-phonologicalrules in polymorphemic words
Knowledge of markers for case,person, number, gender, awarenessof agreement features

Knowledge of inflections,derivatives and compounds

Knowledge of markers for case,person, number, gender, awarenessof agreement features

Vocabularyknowledge

Grammarknowledge

Note: based on work by Elinor Saiegh-Haddad1, Sonali Nag2, Catherine Mcbride-Chang3 and Margaret Snowling4

Phoneme and rime level

Level of word, morpheme, syllable
and phonetic radicals

Level of syllable, phoneme andonset-coda

Level of word & morphemes
especially for unvowelled text andhomographs

Sound-symbol
mappings

Knowledge of tense markers,
constraints of word order

Knowledge of exception words,
inflections, derivatives andcompounds

Letters and legal letter sequences

Characters, phonetic radicals,
knowledge of specific characters forhomophones

Akshara, diacritics and ligaturingrules, knowledge of akshara-syllable
mappings

Letters and diacritics, symbol form
according to position in word

Orthographic
knowledge

Phonemes

English4

Syllables and lexical tones

Chinese3

Syllables and phonemes

Kannada2

Phonemes

Arabic1

Foundation skills are broadly similar across writing systems.

PhonologicalskillsTable C.3.2

IACAPAP Textbook of Child and Adolescent Mental HealthAncient rock art and inscriptions, Edakkal,
India. (Picture: G. Arulmani)

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IACAPAP Textbook of Child and Adolescent Mental Health

LITERACY DIFFICULTIESIn this section we will review what we know about literacy difficulties: howcommon are they in the population, what their clinical picture is and what weknow about their etiology. We will also discuss current trends in assessment andintervention. The literacy difficulties we focus on are not just limited to thosechildren who fulfill the criteria laid out in the diagnostic manuals. We also focus
on children who are in the mild to moderate range for literacy delays, reflecting theknowledge that reading (and spelling) is a continuous trait. This is in keeping withthe view that both the risk factors for specific learning difficulties and the manifest
clinical picture are dimensional in nature rather than simple, categorical entities(see Chapter A.3).
Epidemiology
Information from epidemiological studies helps us understand how
common a particular difficulty is by checking its frequency in a population. Suchstudies also gather information about the distribution of the problem – whether it
predominantly occurs in a particular location, in which age groups the problem isobserved, what are the circumstances under which the clinical picture changes, andwhether there are differences in occurrence over time. Analyses of this kind help
us gain a better understanding of the multiple factors that shape the manifestationsof a difficulty, as well as to develop appropriate policies for people who are affected.
A review of published epidemiological studies suggests similar trends acrosscountries; this is not surprising since prevalence rates depend upon the precise
criteria used to define these disorders and different studies tend to adopt similar
cut-offs – e.g., lowest 5% or 15%: USA (Shaywitz, 1998), India (Nag, 2000; Nag &Snowling, 2010). Accordingly, narrow band definitions of reading disorders basedon conservative cut-offs place the prevalence rates of specific learning difficulties
between 4% and 8%. In contrast, broad based surveys that identify poor readers
due to multiple underlying causes show prevalence rates of up to 18%. Incidence
rates appear to increase over the early school years, with estimates showing a peakaround the end of primary school (age 8-10 years), and new “cases” continuing tobe identified through middle and high school, higher education and beyond.
The components of literacy that are prioritized for surveillance of literacy
difficulties change over the school years, usually reflecting prominent concerns ofcommunity leaders, parents, teachers and clinicians for each level of schooling (seeBox in next page). In the primary school years, the focus is on children’s difficultywith word-level decoding skills. By middle school, in addition to the children who
already show an early disadvantage because of poor word decoding attainments, asecond group of late-emerging poor readers also begins to be identified. These arepoor readers with more or less adequate word-level decoding skills but substantiallypoor reading comprehension skills. From this level of school onwards, difficulties
with spelling and expressive or narrative writing also attract diagnosis. In older
children, adolescents and adults, more “cases” may be identified depending on
the formula adopted by the particular survey for categorizing low achievement.
However, when a consistent cut-off is used, estimates appear to be more stable.
For example, in a longitudinal study over a three year period, the number of poor
readers was 16% (Vellutino et al, 2008) though this need not imply that the samechildren are affected at each stage.

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IACAPAP Textbook of Child and Adolescent Mental HealthAn example of a framework for monitoring reading attainments: The SACMEQ* II surveys
A group of countries in Africa have been conducting cross-national surveys since the 1990s. Called
the Southern and Eastern Africa Consortium for Monitoring Educational Quality (SACMEQ), the group
comprises the ministries of education in southern and eastern Africa1. Given below are the levels of
reading assessed in the SACMEQ II Surveys (2000-2003):
Level 1. Prereading: matches words and pictures involving concrete concepts and everyday
objects.
Level 2. Emergent reading: matches words and pictures involving prepositions and abstract
concepts; uses cuing systems to interpret phrases by reading forward.
Level 3. Basic reading: interprets meaning (by matching words and phrases completing asentence) in a short and simple text.
Level 4. Reading for meaning: reads forward and backward to link and interpret information
located in various parts of a text.
Level 5. Interpretive reading: reads forward and backward to combine and interpret informationfrom various parts of a text in association with (recalled) external information thatcompletes and contextualizes meaning.
Level 6.

Inferential reading: reads through longer (narrative, expository) texts to combine
information from various parts of a text to infer the writer’s purpose.

Level 7. Analytical reading: locates information in longer (narrative, expository) texts to combine
information to infer the writer’s personal beliefs (value systems, prejudices, biases).
Level 8. Critical reading: locates information in longer (narrative, expository) texts to infer andevaluate what the writer has assumed about both the topic and characteristics of thereader (for example, age, knowledge, personal beliefs, values).
*
SACMEQ member countries are Botswana, Kenya, Lesotho, Malawi, Mauritius, Mozambique, Namibia, Seychelles, South Africa,
Swaziland, Tanzania (mainland), Tanzania (Zanzibar), Uganda, Zambia, and Zimbabwe.

Multiple contexts
Epidemiological data are sensitive to local conditions. For example, in an
epidemiological survey in the city of London, UK, the prevalence of dyslexia wasput at 3% in the metropolitan area while in another survey using exactly the same
tools and criteria for identification, prevalence rate was 6%. The second survey wasin the more deprived inner city schools (for a review see Rutter & Yule, 2006).
A similar picture of the impact of socio-economic disadvantage is available
from surveys in the Southern Indian city of Bangalore where socio-economic
circumstances were more crucial in explaining prevalence rates than children’s
language of literacy learning. Among schools catering to families belonging to the
middle socio-economic classes and offering reading instruction in a non-dominantlanguage (English), the prevalence rate was 18%. However in an institutional
home for children in conflict with the law who were learning to read in their homelanguage (Kannada), the prevalence rate jumped to 60% .
It is important also to note that most currently available epidemiologicalinformation is from high income countries. What this means is that data comefrom a particular type of schooling environment that typically subscribes to a
mono-grade organization and strict age-grade stratification, class sizes are small tomoderate and teacher: student ratios are healthy. Many of these schools are able
to offer literacy instruction in the child’s home language, or have well developed

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IACAPAP Textbook of Child and Adolescent Mental Healthbridge programs for transition from the home language into the school language.
However, in many low and middle income countries, school arrangements may bequite different. Schools may have multi-grade classrooms (e.g., children between
the ages of 5 and 8 studying in one group, with instruction spanning grades 1 to
3). Age range within a class may be quite large. For example, in a survey of about
8000 children in Uganda, the average age in grade 3 was around 10 years and theage range was between 6 and 15 years (UNEB, 2008). Schools may be informal
or non-formal, with school timing being customized to the target group in theregion (e.g., children who work with their families for a living). In these countries,
the language of literacy instruction is often not the same as the home language,and language programs to ease the transition into the school language may be bypassed. In addition, teacher: student ratios may be unreasonably large (even up to
1:120 in some cases). It is clear that in these settings, prevalence rates cannot beeasily predicted from what is documented in high income countries.
Further complicating the picture are the multiple sources of influenceon the pace of literacy learning. The nature of the writing system, the child’s
proficiency in the language of literacy instruction and the effectiveness of the
instruction program can all change the rate at which children become skilled inliteracy. The variable trajectories of literacy learning need to be factored in when
making definitions of who has a literacy difficulty. Table C.3.3 lists some of theparameters that can change the estimates of school learning and therefore define
the local conceptualization of school underachievement.
Table C.3.3

Some influences on the pace of literacy learning.

Parameters that can influence
the pace of learning•

Likelihood of longer learning time••

Are the links between the symbols and the sounds
clear and consistent?
Is the writing system transparent or opaque?

With opaque writing systems (e.g., Portuguese,
English, Japanese kanji, Tamil, Bengali, Arabic,
Hebrew)••

How many symbols are there in the writing system?
Is the symbol set contained or extensive?

•

With extensive writing systems (e.g., Chinese, Indian
akshara)•What is the morpheme length of most words in thelanguage of literacy?

•

When words contain many morphemes and there
are word internal changes either at the level of one
morphemic unit or a morpheme boundary•

What are the types of inflections in the language ofliteracy?

•With less productive inflections, greater distance
between agreement features•

Is literacy learning occurring in the first, second, thirdor another later-learnt language for the child?

•

When literacy is in the less dominant language (e.g.,
in many parts of the Asia Pacific, Africa and Central
Europe)•Is the child learning to read in more than one
language?
Is the child receiving literacy instruction to become biscriptal or multi-scriptal?

•

When literacy instruction is simultaneous in more than
one language (e.g., many parts of South Asia)•

Is the literacy instruction of appropriate quality andadequate duration?

•

With poor quality teaching and insufficient duration ofteaching•

Is the home and community environment nurturing ofliteracy?

•

In non-nurturing environments for literacy
development•

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IACAPAP Textbook of Child and Adolescent Mental Health

Epidemiological data not available
It should be clear by now that the cut-offs used for epidemiological surveys
of literacy difficulties are externally defined by the context, and rates reported
from epidemiological studies in one context must be interpreted cautiously inother contexts. Keeping this in mind, we suggest that it is best to begin with abrief survey in locations where epidemiological data are not available. A survey
can help to understand the local prevalence rates of the literacy difficulty indifferent age bands and its distribution across locations (e.g., public vs. private
schools, mother tongue schools vs. other language schools, poorly functioning
schools vs. well functioning schools). The following are examples of tools forsurveys:••

Progress in International Reading Literacy Study (PIRLS) – Student
Questionnaire (2001)
The Child Development Index (Nag & Arulmani, 2006 p30). This
questionnaire is for village community workers.

Clinical picture
Dyslexia
Although dyslexia was originally described by medical practitioners who
focused on what they considered to be visual impairments, a landmark review
pointed also to a variety of verbal deficits (Vellutino, 1979). In due course, andwith evidence from several strands of research principally with alphabetic languages,
the verbal deficit hypothesis evolved into the now dominant view that the core
deficit in dyslexia is in the phonological domain and encompasses overlappingdifficulties in phonological awareness, phoneme segmentation, phonologicalmemory and phonological learning (Vellutino et al, 2004). Finally, though not
yet fully understood, are deficits in rapid automatized naming, which requires theefficient retrieval of phonological codes (verbal codes like letter sounds, number
and color names) from their visual forms (letters, digits or color swatches). Rapid
automatized naming deficits have been found in semanto-phonetic Chinese scripts
like Cantonese and Mandarin, the alphasyllabic scripts like Kannada and Korean
and alphabetic scripts like Arabic, English, German and Greek.
An explanation of dyslexia that is entirely drawn from within thephonological domain is, however, insufficient to cover the range of deficits foundamong poor readers, particularly in the non-alphabetic writing systems. Ho et al(2002), for example, found that 50% of all poor readers were slow in rapid naming,
39% and 37% showed lowered orthographic processing (symbol awareness) andvisual processing respectively, and 15% were poor in phonological processing. In asimilar multi-factorial explanation for reading difficulties for Kannada, a languageof South India, Nag and Snowling (2010) found that all poor readers were poorin symbol knowledge (in this case akshara knowledge), 62% were slow in rapid
automatized naming, 60% were poor in phonological processing, 14% in visual
processing and 62% in oral language. Findings from surveys such as these strongly
endorse a multiple-deficit view of reading difficulties (Pennington, 2006). It isclear from these and several other cross-linguistic studies that explanations of poor
reading, reading difficulties and dyslexia have to take into account domains of oral
language, attention and visual processing and orthographic knowledge.

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IACAPAP Textbook of Child and Adolescent Mental Health

Two distinct forms of reading difficulty. In dyslexia the clinical picture ischaracterized by compromised decoding skills while comprehension skills are intact(either appropriate or above expectation for the child’s age, grade or generalabilities). There is however a second group of struggling readers who are poor
in reading comprehension. While their decoding skills are appropriate for age,
grade and general ability, they lag behind in comprehension skills. Figure C.3.6
below shows the difference in the attainment profiles of the two groups. Thereis converging evidence from several cross-linguistic studies that such discrete
profiles are often seen among poor readers. This suggests a double dissociation
between phonological skills for reading (decoding) and semantic skills for reading(comprehension).
A dimensional view of dyslexia. Figure C.3.6 presents reading difficulties asa modular phenomenon. There are however several challenges to such a neat,categorical view of dyslexia and literacy difficulties. The field of behavioral genetics
has shown that genes have rather general effects and hence are unlikely to produce
such neat dissociations with any frequency. Furthermore, single-deficit accounts failto explain why some children succumb to reading impairments while others, withsimilarly affected processes, do not. Moreover, literacy difficulties show continuities
with language impairments and co-morbidities are common. It is against thisbackground, that the proposal of a dimensional view of developmental disorders
has been made (see Hulme & Snowling, 2009 for a review). Developing this lineof argument, a recent review in the UK concluded that dyslexia is a dimensional
disorder with no clear cut-offs (Rose, 2009). Co-occurring difficulties include
problems with language, motor co-ordination, mental calculation, concentrationand personal organization, though it must be noted that none of these are, bythemselves, markers of dyslexia.

Figure C.3.6 Two distinct attainments profiles: Children with dyslexia and poor
comprehenders (Poor Comp).

A non-wordreading test
A readingcomprehension
test
Averageperformance of
normative
sampleSpecific learning difficulties

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IACAPAP Textbook of Child and Adolescent Mental HealthA corollary of this view is that whether or not a child develops dyslexia
depends both on the number of risk factors a child carries and their severity. Thus,
mild phonological deficits may be easily compensated. However, more severe
phonological deficits will impact on phonological decoding skills and spelling
accuracy. More information for a multi-factorial understanding of the dimensions
and risk factors in dyslexia comes from surveys. In Chinese, Ho et al (2002) foundthat more than 50% of poor readers had cognitive deficits in three or four domains
while less than 25% of poor readers had difficulty in just one domain. Similarly,
for Kannada, Nag and Snowling (2011) found that 13.8% of all poor readers had
deficits in the five domains examined in the survey: oral language and speed ofprocessing, and the orthographic, phonological and visual processing domains.
Developmental Trajectory. It has been known for many years that dyslexia
runs in families and recent studies suggest there is about a 40% risk of dyslexia infirst degree relatives. Although debated, there appears to be a greater likelihoodof a boy being affected than a girl, perhaps because dyslexia is associated with
developmental language problems which are more common in males. Althoughdyslexia is most usually diagnosed in middle childhood it is clear from longitudinalstudies that its effects are evident as early as age three and persist through adolescence
into adulthood. Table C.3.4 shows the risk factors for dyslexia at different stagesof development.
Children with reading comprehension impairment
These children (sometimes referred to as poor comprehenders) have a patternof reading difficulty that contrasts sharply with dyslexia. They can read words andTable C.3.4
Risk factors and behavioral symptoms indicative ofdyslexia at different developmental phases.
STAGE OFDEVELOPMENTRISK FACTORS FOR DYSLEXIA

Birth

•

Affected family member

Preschool•••

Late talker
Speech difficulties
Slow to learn colors and letters

School entry••

Poor knowledge of letters
Poor rhyming or phoneme skills

•
•
•
•
•
•

Expressive language difficulties
Small sight vocabulary
Problems reading novel words
Spelling difficult to decipher
Poor written expression
Verbal working memory impairments•••

Low level of reading fluency
Spelling problems
Written work below expectation based on verbal
performance
Inattention
Poorly developed study skills
Often academic self-esteem is low

Middle school

Secondary schooland beyond•••

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IACAPAP Textbook of Child and Adolescent Mental Healthspell words accurately but have problems understanding the meaning of what theyread. The poor comprehender’s profile can be seen on its own or in combination
with other disorders, for example, autism, when the term “hyperlexia” is sometimes
used. As a group, poor comprehenders have been much less studied than children
with dyslexia and the condition is not well recognized by teachers even though, inalphabetic contexts, studies suggest that between 6% and 10% of primary school
pupils appear to be affected (see Hulme & Snowling, 2010 for a review). Reading
comprehension impairment may therefore be considered a “hidden” disability
associated with underachievement.
Given that the specific problems experienced by poor comprehenders are in
reading for meaning, it is not surprising to find that their language skills are weak inrelation to non-verbal intelligence. In contrast to dyslexia, they show normal levelsof phonological awareness, rapid automatized naming and phonological learning
but they have difficulties with semantic processing and in grammatical skills. They
also show a range of difficulties in higher-level text processing, such as problems
with making inferences, especially across large sections of text where verbal
working memory is involved, knowledge of story structure and comprehension
monitoring. The findings of a small number of prospective longitudinal studies ofpoor comprehenders suggest that their cognitive profile is stable over time and theskills which they bring to the task of reading include well developed phonologicalskills coupled with vocabulary impairments.
Turning to bilingual and multilingual children, we now know that some
aspects of the broader oral language develop faster than others in the languages
learnt later – sometimes referred to as profile effects (Oller et al, 2007). In SpanishEnglish and Turkish-English bilinguals for example, English vocabulary and thecomplex grammar such as seen in passive sentences are slower to develop thansimple grammar (Bodman et al, 2010; Chondrogianni & Marinis, 2011; Oller etal, 2007). It follows that many children who are learning to read in a non-native
language will be at risk of reading comprehension impairment associated with
their limited command of the language of instruction. Similar trends were also
seen in a recent survey in the UK for the standardization of the York Assessmentof Reading and Comprehension. Secondary school pupils who had English as anadditional language did as well in word-level reading as their monolingual English
peers but had significantly poorer reading comprehension. Broadly similar profile
effects have been reported among learners of other languages.

AETIOLOGY
Dyslexia
It is now well established that reading and phonological skills are highly
heritable and hence dyslexia runs in families (Pennington & Olson, 2005). A
recent behavior-genetic analysis of Chinese-speaking children suggests this is likely
to be the case across languages (Chow et al, 2011). Importantly, however, some ofthe shared genetic variance between twins is due to gene-environment interaction.
Thus, the home literacy background provided by more literate parents may foster
reading skills, and better readers may themselves actively seek out more literaryexperiences; it can be expected that such gene-environment interactions will playout differently in low and middle income countries.

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In the proposed DSM-5,
reading comprehensiondifficulties are simply listed
as a symptom of language
impairment, rather thanas a disorder per se, adecision which has caused
consternation.

Second language
The initial phases oflearning additional
languages can be slow,
leaving many clinicians
confused about when to
assume that the child will
“catch up” and when toassess for dyslexia. For an
online resource on issues
related to second language
learners and the diagnosisof literacy difficulties, clickon the picture above.

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IACAPAP Textbook of Child and Adolescent Mental HealthStudies of the molecular basis of genetic influences on reading have used
a variety of methods. To date, the strongest evidence for linkage with dyslexia(in terms of number of replications) is a site on the short arm of chromosome
6, and currently molecular biologists are having some success in identifying
candidate genes. It is important to remember, however, that genetic influences areprobabilistic; disorders like dyslexia depend on the combined effect of many genes,
as well as on environmental influences.
It has been reported that there is a wide range of structural and functional
brain differences between people with dyslexia and controls and an exciting line ofresearch is exploring whether candidate susceptibility genes for dyslexia are also
responsible for subtle cortical abnormalities that are related to neuronal migration
and axon growth. The use of neuroimaging to identify which brain systems might
be impaired in dyslexia holds great promise, although there are still methodologicalissues to resolve. For example, if one group suffers from a reading disorder andthe other group does not, their performance on reading tasks will differ and so will
their reading experience. These methodological problems will be compounded
when one considers people who are learning to read in a language that differs fromthe home language, and people who are bi- or multi-scriptal.
Notwithstanding these concerns, a recent meta-analysis (Richlan et al,2011) reported underactivation in inferior parietal, superior temporal, middle
and inferior temporal and fusiform regions of the left hemisphere in people withdyslexia during reading or reading-related tasks. In addition, there were left frontal
abnormalities in the inferior frontal gyrus accompanied by overactivation in the
primary motor cortex and the anterior insula. The studies reviewed were fromseveral European languages, the assumption being that these patterns are universal
across alphabetic writing systems. At the time of writing, the evidence pertaining
to brain activation in dyslexia in non-alphabetic languages is in need of replication.
More generally, the causal status of brain differences in dyslexia is debatable; brain
development shows considerable plasticity and both its structure and function are
shaped by use.
Reading Comprehension Impairment
Much less is known about the etiology of reading comprehension impairment.
The gender ratio appears to be more equal than in dyslexia but epidemiological
data are sparse. It seems probable, given its association with language impairment,that genetic influences on reading comprehension impairment will be substantial.
Preliminary data from behavior genetics suggest this is indeed the case but findings
are in need of replication.
Social and environmental influences
Aside from biological and cognitive factors, it is important not to overlook
the critical role of the environment in shaping a child’s literacy development.
Evidence indicates that reading disorders show a strong social gradient and surveys
suggest that poor readers often come from large families, where later-born children
may face delays in language development. Direct reading instruction in the homeis also important, as different styles of home literacy are associated with individual
differences in the pre-reading skills which children bring to school (Senechal &LeFevre, 2002). In turn, schooling can make a substantial difference to reading

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The social andenvironmental context
is a complex, multidimensional construct.
However, researchers
reduce measurement of thisconstruct to a manageable
set of measures, common
proxies being mother’s
educational level, enrolment
in welfare schemes suchas school lunches, andlocation of schooling, suchas the school district andgovernment vs. private
ownership of the school
the child attends. A
good starting point whenattempting to understandreading disorders in low andmedium income countries isto develop a picture of thesocial and environmental
context. Click the picture
above to see a descriptionof the multiple dimensionsof social and environmental
realities of primary school
children in the Southern
district of Chamarajanagara
in India.

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IACAPAP Textbook of Child and Adolescent Mental Healthachievement (NAPE 1999- 2008). In addition to these factors, being a poor reader
affects the motivation to read. From very early in development, children differ intheir interest in books, and children at risk of dyslexia may well be among those
who are more difficult to engage.
One variable that can have a significant impact on the behavioral
manifestations of a reading disorder is reading practice which, in turn, depends
on “print exposure”. Indeed, the effects of low exposure are cumulative, causing
differences in reading competence to become magnified over time. Whilepoor comprehenders can read fluently, it is unlikely they will read for pleasure.
It follows that low levels of motivation for reading may affect these children as
much as children with dyslexia and there will be a wide range of sequelae affectingclassroom performance and achievement in school.
In summary, as might be expected for a complex skill such as reading, theetiology of reading difficulties and reading disorders is varied and depends on both
genetic and environmental factors. Some children carry a genetic risk of dyslexia
but whether or not they are classified as dyslexic depends upon the particularlanguage and school context in which they learn and the other skills (or deficits)
they bring to the task of reading. A dimensional view of literacy difficulties moves
us to think of the causes of disorders as not just multi-factorial but also as occurring
due to the accumulation of risk and protective factors that shape (moderate) its
manifestation.

ASSESSMENT
Research from multiple languages has given us insights into the componentsof literacy and associated cognitive domains that need to be assessed to gain
insights into a child’s literacy learning difficulties. This section lists these domains
and gives examples of tasks that have been shown to be useful for assessment.
Where possible, sample items are included. This section does not suggest specifictests. This is because literacy and language tests are useful only if they assess skills
and knowledge that are known to be specifically associated with particular writing
systems and languages. Moreover, tests are valuable only if they have been locallystandardized.
A framework is described in the box below that draws upon a multi-factorial
view of literacy development, a dimensional view of learning difficulties and the
A broad framework for assessment
1.
2.
3.
4.

Literacy learning occurs within the larger context of language and its functions.
Assessment of literacy learning difficulties must cover the sub-skills of language
development
Literacy learning has multiple foundations. Assessment must be across multiple
cognitive domains
Criteria for literacy difficulties are moderated by local context. Assessment resultsmust be interpreted in comparison to only those who have closely similar linguistic,socio-economic and teaching histories
Dyslexia and learning difficulties are dimensional constructs shaped by multiple
factors. Assessment must not only comment on the current clinical picture but also
the ‘risk’ and ‘protective’ factors concurrently documented.

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IACAPAP Textbook of Child and Adolescent Mental Healthacknowledgement that the cut-off for diagnosis is externally negotiated based on
the local context. Apart from these theoretical underpinnings, it is also importantto recall two trends in diagnosis: the use of discrepancy criteria is increasingly
falling out of favor and the use of a response to intervention approach is particularly
relevant when children have had low opportunity for quality instruction.
A comprehensive assessment of literacy needs to document attainments incomponent skills such as:• Letter knowledge• Reading accuracy• Reading speed• Reading comprehension• Spelling accuracy• Rate of writing, and• Quality of written expression.
On the other hand, an assessment of the supporting foundations for literacy
needs to cover both language and cognitive domains. The language domains ofinterest are the broader skills associated with semantics, morphology, syntax andpragmatics as well as the more basic skills associated with phonological processing.
Other domains of interest are general abilities and non-verbal processing, visual
processing and speed of processing. There is increasing evidence that learning
difficulties co-exist with other difficulties (comorbidities). Should there be any
indication of additional areas of difficulty, these too need assessment.
A final point has to do with sources of information about these domains. A
prudent approach would be to collate information from multiple sources rather thandepending on a single source or test. Table C.3.5 gives the domains that must be
assessed and Tables C.3.6 to C.3.8 show the tasks that can be used.
Ideas for assessment of general cognitive and perceptual skills
General abilities

Click on the picture toaccess a Special Issue of
the Journal of Pediatric
Psychology on ADHD, its
co-morbidities and links toschool underachievement(open access).

Culture fair tests are difficult to find. The test with the most widespread use
currently is the Raven’s Progressive Matrices.
Speed of processing
This can be done with a collection of tests that time children’s performance,such as visual search or coding from the Wechsler tests. More specific tests linked
to literacy performance include the rapid automatized naming task and timed
tasks of phonological manipulation (examples in Table C.3.7).
Visual processing
The use of visual processing tasks in literacy assessment is gaining interestfor languages with extensive, visuo-spatially complex symbol sets. There are several
ways in which visual processing has been assessed. One set of tasks targets visual
short term memory, where children have to recall just shown visuals of different
orientations and degree of detail. Another set of tests assesses visual sequential
memory where strings of visuals are shown and children have to recall the target
string from a set of distracter sequences.

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IACAPAP Textbook of Child and Adolescent Mental Health

Table C.3.5

Areas of assessment that are of diagnostic importance

LITERACYSKILLSPHONOLOGICALPROCESSING

BROADER ORALLANGUAGE

OTHER AREAS

POTENTIAL COMORBIDITIES

•

•

•
•

•

•

•
•
•
•
•

Symbolknowledge
Reading
accuracy
Reading speed
Spelling
Readingcomprehension
Expressive
writing - quality
and rate

Table C.3.6

•
•
•
•

Phonologicalawareness
Syllable
processing
Phonemeprocessing
Verbal shortterm memory
Rapid
automatizednaming•

Vocabulary
Grammarknowledge
Knowledge of
inflections••

Generalcognitive
abilities
Speed ofprocessing
Visualprocessing

•

•
•

•

Attention
deficits
SpeechsounddisordersNumeracydifficulties
Motor
coordinationdifficulties
Anxietysymptoms

Sample tasks for assessment of literacy skills.

Symbol Knowledge: assessed by giving a list of the symbol set of the writing system.
••

For contained orthographies all symbols are shown.
For extensive orthographies, symbols are chosen according to some agreed criteria.
For the akshara languages for example, the list may be sets of Ca, CV and CCV
symbols.

Reading and Spelling accuracy: assessed using both lists and sentences.
•••

Word can be graded for frequency, regularity and length of words. School textbooks
can sometimes be a good source for constructing these tests.
If words in the language require oral language skills for accurate decoding (seeexamples in pgs 12-13), consider adding such words as a subset in the list.
Non-word lists can be developed by changing one or more symbol units in words.

Reading speed: typically assessed as number of words correctly read per minute.
Reading comprehension: assessed using single sentences and longer passages.
•••

Both factual and inferential questions are necessary.
Asking to give a title to a passage is a useful way to capture comprehension.
Using multiple choice questions is a useful way to capture comprehension if children
are reticent or not very fluent in the language (e.g., with second language learners).

Expressive writing: assessed using narrative skills on a prescribed topic or a self-chosen topic.
•••

Rate of writing – number of words per minute.
At the word level, writing may be assessed for spelling, use of particular grammaticalstructures like adjectives, connectors and determiners and use of dialect words.
For the narrative, assessment parameters include sequencing, style and usage.

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IACAPAP Textbook of Child and Adolescent Mental Health

Table C.3.7

Sample tasks for assessment of phonological processing

Phonological awareness: assessed using segmentation and blending tasks.
Sample: Break up ‘lomputer’ into small sounds. Response expected from child: ’lom-pu-ter’Sample: Join the following sounds: ‘gu – ha – na’. Response expected from child: ‘guhana’Phonological processing: assessed by asking child to manipulate a target sound. Sample of syllable
and phoneme processing tasks using non-words:
Type of Task

ArabicBengali

ChineseEnglishDeletion of initial syllable*
Target item

wahid - /wa/baro - /ba/túshū- /tú/fifty - /fif/

Expected response

hid

ro

shū

ty

Deletion of initial phoneme*
Target item

wahid - /w/

baro - /b/túshū- /t/

fifty- /f/

Expected response

ahid

aro

úshū

ifty

baro - /o/túshū- /ū/fifty - /y/Deletion of final phoneme*
Target item

wahid - /d/Expected response
wahi
bar
túsh
fift
*may also be administered as a timed task for additional information about speed of processing
Verbal short term memory: assessed by asking child to repeat 2 to 5 or 6 just heard items• Non-word repetition using syllable strings (e.g., supila, mantockvip, kavasinuta).
• Digit span using numbers (e.g., 2-9, 2-5-8, 4-6-9-2).
• Word span using early acquired words (e.g., pen, leaf, cup, tin).
• If using digits and words, items should be similar in length (e.g., all bi-syllabic).
Rapid automatized naming: assessed by asking children to read out quickly a neatly laid out set of
digits, symbols or colour swatches.
• If using digits and colours, items should be similar in length (e.g. all bi-syllabic).

Attention
Many children with ADHD read well, though some experience problemsof reading comprehension owing to its working memory and executive demands.
However, there is a strong tendency for dyslexia to co-occur with symptoms of
inattention and recent genetic data suggest a common genetic basis. It follows
that it is important to make an assessment of a child’s ability to control and sustain
attention. Ideally, information should be sought from parents and teachers and in
this regard rating scales are popular. The Strengths and Difficulties Questionnaire(SDQ, Goodman, 1997) includes 5 questions pertaining to attention and canprovide a screen for “hyperactivity” and poor attention. It is also useful to
supplement these data with behavioral observation in the classroom.
Motor coordination
Developmental coordination disorder (also called dyspraxia) is one of themost common co-morbid conditions of childhood. Its nature and developmental

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Developmental
coordination
disorderA developmental disorderin which children fail todevelop normal motor
coordination in the absenceof general learning
difficulties. The disorder canaffect both fine and grossmotor skills, and is present
despite the individuals
having had similar
opportunity to gain motor
skills as their peers.

31IACAPAP Textbook of Child and Adolescent Mental Health

Table C.3.8

Sample tasks for assessment of broader oral language skills

Vocabulary: assessed by asking for picture names or definitions (expressive vocabulary);
vocabulary knowledge can also be assessed using picture-word matching (receptive vocabulary)•

Word lists must be graded for age of acquisition, concrete and abstract words, and frequency.

•

A scheme for scoring child’s response: errors (Sc = 0), passive use of word in idiomatic language(Sc = 1), use of word in sentence form (Sc = 2), definition, equivalent word from anotherlanguage (Sc = 3)•

If using pictures, trial for cultural appropriateness and clarity of illustrations. See example below,
target item is ‘rainy’.

Grammar knowledge: assessed using a variety of tasks, three are listed here.
•

Sentence Repetition task: children are asked to repeat a just heard sentence (e.g., Item: ‘thecats ran to the milk store’ Child’s response: ‘Cat run to milkshop’)•Grammaticality Judgement task: give a mix of grammatically correct and incorrect sentences
and ask child to identify which one is in error.

•

Pointing to pictures (receptive task, useful for reticent children, second language users andchildren with working memory difficulties): have a set of four pictures broadly linked to asentence. Call out sentence and ask child to point to the most appropriate picture.

Knowledge of Inflections: assessed by focusing on inflections in stimuli given to the child•

The sentence repetition task can be used to pick out omissions, substitutions or additions ofinflections (e.g. the child drops plural –s in the ‘cat’ item given above)

Sentence stubs can be used for prompting inflected words. (e.g. to elicit past tense –ed inflections:‘I like to paint. Yesterday I ________ (painted)’.
course together with procedures for assessment and treatment are described in thisdocument. The Dyspraxia Foundation also has a useful website for professionals
and families. It is possible to use the information in these two resources to develop
a checklist which will be useful in the community being served (be it pre-school,
primary or secondary level). In terms of behavioral assessment for a suspected comorbidity with specific learning difficulties, it is important to make an assessmentof pencil control, quality of writing and copying skills. For the older child,producing complex diagrams (e.g., in science) and using scissors and other tools(e.g., for project work in middle school, in vocational courses that are oriented tofine motor skills such as carpentry and in design & technology courses) may posea problem.
Number skills
DSM-5 proposes that dyscalculia be defined as difficulties in production orcomprehension of quantities, numerical symbols, or basic arithmetic operations thatare not consistent with the person's chronological age, educational opportunities, or
intellectual abilities. When numeracy is an issue for a child, it is important toknow if their difficulties are associated with number facts and their manipulation

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IACAPAP Textbook of Child and Adolescent Mental Health

DSM-5 proposes that dyscalculia be defined asdifficulties in the production or comprehension ofquantities, numerical symbols, or basic arithmetic
operations that are not consistent with the person's
chronological age, educational opportunities, or
intellectual abilities.
(arithmetic) or with more abstract mathematical thinking. Many children withdyslexia struggle to learn number facts, especially multiplication tables, but may
be good mathematicians. In contrast, the poor comprehender profile has beenreported to be associated with poor mathematics in the face of well-developedarithmetic skills. It follows that both aspects of numeracy should be assessed.
DSM-5 advocates that multiple sources of information be used to assess numerical,
arithmetic, and arithmetic-related abilities. Where standardized tests are notavailable, it is possible to devise short age-appropriate tasks to tap basic arithmetic
facts, simple addition and subtraction and verbally posed mathematical problems
for solution. The website “About Dyscalculia” provides ideas for observations
teachers can make in the classroom.
Anxiety and coping
Many children with specific learning difficulties experience anxiety in theclassroom and, for some, this may contribute to a more general anxiety disorder.
Similarly, self-esteem is lowered as a consequence of literacy problems since thesecan affect performance in most areas of the curriculum. The SDQ (Goodman,1997) is a useful tool for understanding children’s emotional and behavioral
difficulties. This is a 25 item questionnaire covering emotional behavioral problems,
conduct problems, hyperactivity/inattention, issues with relationships especiallywith peers and the strength of positive social behaviors. There are translations of
this questionnaire in several languages, and importantly, SDQ is an open accesstool (see also Chapter A.5).
Some practical questions
When a child is taken for assessment, some key requirements are theavailability of skilled professionals, reliable testing tools and quality support
services; in many middle and low income countries, access to all three of thesebasic requirements is either patchy or minimal. This is problematic because apoor quality assessment has the potential to mislead or, worse, cause harm tothe child. The most worrisome contexts are where children live in exceptionallydeprived circumstances, school systems do not recognize the learning difficulties,
parents and community elders are unaware about the disorder and provisions andSpecific learning difficulties

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IACAPAP Textbook of Child and Adolescent Mental Health

Table C.3.9 Five questions to ensure ethical practice in theassessment of school underachievement
Is there a collective understanding of the:•Authorized person who can diagnose?
•
Professional protocols for assessment and diagnosis?
•
Classification system and/or diagnostic manual to be followed?
•
Reliability and validity of the tools being used?
•
Follow-up support that will be offered?

hence cannot advocate for the child, professional training programs do not give
up-to-date details about literacy difficulties and their assessment and there are
no standardized tests. Table C.3.9 shows a set of questions that can be asked insuch situations. Articulating answers for these questions can help set the agenda
for developing an assessment system for screening and identification of specificlearning difficulties in communities where such a practice is not yet mature.
The move is towards resource intensive assessment devices. A gold standard
for assessment is an individually administered test that has sound psychometricproperties. This is often an expensive proposition, requiring not just theoreticalexpertise but also large numbers of personnel to collect and analyze thestandardization data. Many middle and low income countries are nowhere neardeveloping such tests.
A first step could however be to develop informal graded tests. These tests
are based on locally sourced materials which are not expensive to collate (e.g.,
textbooks, recordings of children’s speech and local stories). The types of tests
could be around the tasks suggested in Tables C.3.5 to C.3.8. These informal tests
can begin to reveal children’s profiles of strengths and difficulties and allow for
the first level of identification. More importantly, these tests can give a wealth of
information for developing focused interventions.
A second step would be to identify who are the most vulnerable. This can bedone through collecting local data and using an arbitrary cut-off. A useful cut-off
for identifying the most vulnerable is to pick all those children whose scores fall
below 1.5 standard deviations of the mean score on a test. An even more stringent
cut-off may be preferable in unstable contexts (e.g., frequent school closure,recently changed language of instruction, a recent traumatic event in the region
like a war or natural disaster). The local data can be from a selection of schools
and the main expense here is the mass production of the tests and time needed toprepare, administer, score and identify the mean scores and standard deviations
for each test.
A logical next step would be to develop standardized tools. Such an enterpriseshould follow from a theoretical model of how literacy is acquired in the languageof interest, and a good grasp of the sample characteristics of the region. In contexts
where standardized tests have been developed, it is useful to remember that norms
change over time and hence, tests should be reviewed periodically for relevance.

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IACAPAP Textbook of Child and Adolescent Mental Health

INTERVENTION
A good starting point for developing an intervention is an understanding of
the causes of a reading disorder. Indeed targeting impaired processes provides the
motivation for the design and content of an intervention.
For the alphabetic languages, a number of meta-analyses have guided thedevelopment of good practice for the teaching of reading, notably that of the US
National Reading Panel and by the National Early Literacy Panel. In turn, there
are now a growing number of evidence based interventions for dyslexia; a usefulwebsite from the UK is Interventions for Literacy, with intervention ideas forchildren struggling to read in English, both when this is their home language(English as first language) or a non-dominant language (English as second
language).
For lower and middle income countries a good understanding of theprinciples of interventions and their suitability for different children is the first step
to indigenous programs. Snowling and Hulme (2010) reviewed the ingredientsof evidence-based interventions for language and literacy difficulties, and this canbe a good starting point for developing local interventions. Principally it is goodpractice to ensure that interventions:• Are systematic, well-structured and multi-sensory,• Incorporate direct teaching-learning,• Incorporate a good amount of time for consolidation,• With frequent revision, to take account of the likely limited attention
and learning difficulties of the child.

Unfortunately, the field ofdyslexia is plagued withadvertised “cures” whichhave no evidence base. It
is therefore important for
professionals to criticallyreview the content ofprograms to ensure theirsuitability. Click on the
picture to access a video byProfessor Dorothy Bishop
which provides good advice
in this regard.

For dyslexia in the alphabetic languages, effective interventions should
include training in letter-sounds, phoneme awareness, linking letter and phonemes
through writing and reading from texts at the appropriate level to reinforce emerging
skills. In contrast, poor comprehenders require a different “diet” attuned to theirneeds and can benefit from training in oral language skills particularly vocabulary
training, the development of inferencing skills and work on story structure andnarrative. Of course it is important to bear in mind that many children will haveproblems with decoding and comprehension, in which case a mixed approach isneeded.
Websites with ideas for intervention•

Preferably, intervention should be delivered early, focusing on building the foundations for literacy development in theearly childhood years. This Nuffield Foundation website gives ideas for intervention in a pre-school setting, but can also
be adapted to informal groups in the community and within the home•

Interventions for children in primary school can be either in a group setting or one-to-one. The website Reading for
Meaning gives ideas that can be quickly adapted to different languages and writing systems•

Involving parents in supporting their children’s literacy development at home is good practice. This DysTalk video
provides ideas as to what might help both in pre-school and after school entry. Although the video focuses on alphabetic
contexts, the principles are useful for non-alphabetic writing systems also. The key assumption is that parents have a levelof literacy and financial resources to try out these home-based ideas•

These documents from The Promise Foundation give examples of low cost interventions in pre-schools, primary schools
and the community: Handbook on Prevention of Child Labour for Anganwadi Workers and Handbook on Prevention ofChild Labour for Village Community Workers.

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IACAPAP Textbook of Child and Adolescent Mental HealthRole of visuo-motor training for visually complex characters
Some writing systems have more detailed characters than others and hence
writing them requires very well-developed visuo-spatial and motor skills. It has
been suggested that repeated writing of orthographic symbols, for example kanji
for children in Japan (Wydell, 2003) and akshara for children in southern India(Nag, 2011) is good practice. Children in these languages may also benefit frompractice of motor sequences for writing a symbol/ word: in Japan called KUSHO– ‘writing in the air’, in India, writing in sand or traditionally in plates of grains.
These techniques find their parallel in Western cultures in the Fernald method ofteaching which involves tracing letters, which experimental studies have shown tobe effective.
Summary•

Dyslexia and comprehension impairment are dimensional constructs similar
to obesity, hypertension and many other disorders. In other words, thepresence of literacy difficulties is along a continuum of severity and the most
severe among them qualify for a diagnosis as formulated by the diagnostic
manuals.

•

Prevalence across countries range from 4% to 18% depending on thedefinitions used and the cut-off set. Epidemiological data are, however,extremely sensitive to location and definition; in places where there is no
local data available a useful first step is to gather prevalence data. This will
help to clarify the frequency of the difficulty, its distribution and what is thenature of the services that need to be planned.

•

Spoken language is a foundation for reading and literacy. Language skills
may also be an important compensatory resource for children with poor
phonology (dyslexia). Interventions that target broader oral language in earlychildhood and primary school years can strengthen compensatory resources.

SCHOOL UNDER-ACHIEVEMENT SECONDARY TO
OTHER DISORDERS
Childhood psychiatric disorder
An epidemiological survey of 1403 children between the ages of 8 and 12
in the Southern Indian district of Calicut (Kerala State) showed a prevalence ofchildhood psychiatric disorders of 9.4%. There were strong associations withsocio-economic parameters but, more importantly, with both general school
underachievement and specific difficulties with reading and vocabulary (Hackett
et al, 1999). For the city of Bangalore, prevalence was higher: 13 % for psychiatricdisorders among 4 to 16 year olds; up to 10% showed scholastic difficulties andup to 2% showed co-occurring psychiatric disorder and school underachievement(Srinath et al, 2005). Studies in other countries have also shown an association
between literacy difficulties and childhood psychiatric problems. One reason why
academic underachievement may co-occur with psychiatric disorder is because of
the disorder interfering with school attendance. Other reasons could be symptomsof the disorder disrupting concentration during lessons, study time and exams.
Some of the main reasons for dropping school grades are transient adjustments andSpecific learning difficulties

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IACAPAP Textbook of Child and Adolescent Mental Healthpost-traumatic stress disorders. These may follow life experiences such as abuse,
the loss of a parent or events such as war or natural disaster.
Neurodevelopmental disorders
Neurodevelopmental disorders (formerly known as developmental
disabilities and mental retardation) are a related group of conditions associatedwith learning disabilities and school underachievement (see also Chapter C.1).
The prevalence of learning and developmental disabilities in high income countries
is between 10% and 20 % while in low and middle income countries prevalence
may be higher (Durkin et al, 2005). The trends in increasing prevalence rates
in developmental and associated learning disorders in high, medium and low
income countries may have different origins. In high income countries, there
is a discernible growth in recognition of developmental disorders and increased
awareness in the general public, a notable example being the autism spectrum
disorders. For middle and low income countries, two different social health care
processes have been unfolding: on the one hand, there has been a definite reduction
in child mortality but, on the other, there are multiple disadvantages experienced bychildren. As a consequence, more children are at risk for developmental disorders
generally, and for learning difficulties specifically. Given below is an illustrative listof neurodevelopmental sources for school underachievement:•

Genetic: chromosomal disorders such as Down’s syndrome, segmental
autosomal syndromes such as Prader-Willi syndrome, and autosomal
dominant neurocutaneous syndromes, such as neurofibromatosis•

Nutritional: such as iodine deficiency and vitamin A deficiency•

Prenatal or perinatal infections such as toxoplasmosis, rubella, group B
streptococcus and HIV•

Postnatal or childhood infections such as encephalitis, meningitis, cerebral
malaria, polio and otitis media•

Toxic exposure in the prenatal period to alcohol, lead and mercury, andto drugs taken by mother such as antimicrobials (e.g., sulfonamides,
isoniazid, ribavirin), anticonvulsants (such as phenytoin, carbamazepine),and other (such as thalidomide). Lead and mercury exposure continues
to be dangerous in the post-natal and childhood period•

Brain injuries caused by premature birth and birth asphyxia•

Other forms of traumatic brain injuries caused by accidents, child abuse
and neglect•

Chronic disadvantage from poverty, economic backwardness, severe
malnutrition, continuous social deprivation and absence of cognitive
stimulation.

Sensory impairment
Sensory impairments are one of the most obvious causes of educational
underachievement. Although problems of vision or hearing are easy to notice whensevere, like learning difficulties, they manifest along a continuum of severity andsubtle impairments can slip recognition. For example, about 10% of all primaryschool children in low income communities have eyesight problems (Bundy et al,2003), and many among them go undetected. In such undiagnosed cases, children

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DSM-5

Click here to accessthe whole range ofneurodevelopmental
disorders proposed for
DSM-5

37

IACAPAP Textbook of Child and Adolescent Mental Health

may be underachieving at school because the primary difficulty with vision has
escaped notice. Therefore, at a systemic level, the urgent issue is to inform parents,
teachers and children about sensory difficulties (watch Nanna Kannu (My Eyes) to
see an example of a sensitization program targeting children in Southern India).

VisionA simple fact is that properly fitted eyeglasses (spectacles) can in most cases
correct poor eyesight. Eyeglasses also indirectly help in school achievement. One
large-scale study of eyeglasses intervention documented this knock-on effect onschool performance, showing that children who were given glasses “were less likely
to fail a class” (Hannum & Zhang, 2008). However, access to intervention can bea challenge with very few children actually getting spectacles in some exceptionallypoor or marginalized communities. For these children, vision problems goundetected because screening programs do not cover their communities; even
if the vision difficulty is detected, the benefits of treatment may be lost because
eyeglasses are simply unaffordable. The accumulated impact of uncorrected visionon school achievement for such children is substantial.
Moreover difficulties with vision may be accompanied by subtle cognitive
impairments. Children with convergence insufficiency for example experienceblurred vision, double images, headaches and eye fatigue when reading and writing(see case vignette).
Hearing
Hearing problems, like visual impairments, have both direct and indirect
effects on school attainment. If children are unable to hear what their teacher says
and is in too big a class for lip-reading to be useful, then they will be left behindin all areas of the curriculum. More subtle impairments will affect attention
to auditory information and the development of literacy skills. While in highincome countries (e.g., Norway, UK) many children with congenital hearing
impairments are now fitted with bilateral cochlear implants, which significantly
improve their hearing and consequent language development, neither screening
nor implantation programs are widespread in low and middle income countries.
Less severe problems, including conductive hearing loss, may also go unattended.
As discussed above, phonological skills are a foundational skill for word
decoding. It can be inferred that children who are hearing-impaired will be at highrisk of reading problems. However, being hearing impaired does not automatically
imply that children will be limited in their ability to reflect on the sounds ofthe language (Leybaert, 2005). Instead, individual differences in phonologicalprocessing depend upon the availability of speech skills and communication
experiences. Early childhood experiences can either have a high emphasis on
auditory input, amplification, speech reading and cueing (oral-aural mode)
making optimal use of the residual hearing available to the child, or in the useof gestures, signing and finger spelling in conjunction with speech and audition(total-communication mode). It appears that phonological skills are slow to develop
among children exposed to the total-communication mode when compared tochildren exposed to the oral-aural mode. These differences are independent of
the type of writing system the child is learning to read – e.g., the alphasyllabic
orthographies (Vasanta, 2007), the alphabetic scripts (Nielsen & Luetke-Stahlman,

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Nanna Kannu (My Eyes),

Kannada with English
subtitles (5:00). Click on the
picture to view a video clip
to help children talk about
their vision difficulties (fromSouthern India).

Convergence
insufficiency
An inability to focus botheyes simultaneously ona single point at a close
distance, over a sustained
period of time. Typically,
one eye will turn outward
when focusing on a wordor object from closer than acertain distance.

Poverty, visiondifficulties andlearning
Click on the picture to accessfindings from a survey inrural China. Similar trends
have been reported inseveral other low income
communities.

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IACAPAP Textbook of Child and Adolescent Mental Health

Case Vignette: Vision difficulties and school under-achievement
NT began avoiding books in pre-school. He particularly seemed to avoid reading under bright
lights (“I really like working in the dark… mostly I don’t like tube light”). It was sometime
before a specialist recognized that NT had convergence insufficiency – a disorder of nearvision where the two eyes have a strong tendency to drift outwards rather than to cometogether and work as a team. If both eyes do not aim at the same spot, many activities
become difficult – including reading and writing.
NT began exercises to help both eyes cooperate; by grade 5 the convergence difficulties
had begun to improve. NT reported “I am no longer seeing double” when reading “very small
words”’. However, subtle difficulties with school work remained. The first assessment forschool underachievement showed NT was reading more than three years below his gradelevel. Simultaneously he was showing significant anxiety. The challenge at this stage wasto identify if school under-achievement was stemming from the vision difficulties, the severe
anxiety, or an independently occurring dyslexia or language impairment which had gone
undetected. The source of NT’s reading difficulties became clearer over time. Two years
later, with anxiety substantially under control, his delay in literacy attainment continued.
When reading he showed low accuracy, particularly for unfamiliar words (“phonograph” red
as “photography”). However, on phonological tasks his performance was above average forphoneme segmentation, deletion and substitution. This (among other tests) confirmed thatliteracy difficulties were not because of poor phonological-decoding skills, and thus ruled out
dyslexia. In addition, his grasp of grammatical structures as well as vocabulary was aheadof his age and grade, ruling out difficulties subsequent to language impairment. With thecontribution of anxiety controlled for, the assessment confirmed the presence of learning
difficulties secondary to vision difficulties.
As is the case with many learning difficulties, the domains of difficulty persisted into highschool. At age 16, NT’s reading accuracy for low frequency words was low, with a reading
delay of 2 years. Further, he read approximately 105 words per minute and, when tired, lessthan 70. This reading speed is exceptionally slow: by 13 to 15 years of age, a range of 170
to 200 words per minute is expected. NT’s cognitive attainments were also uneven. On a
standardized test (WAIS II), NT was exceptional in verbal comprehension ( 93rd percentile),
average in working memory (55th percentile) but borderline in processing speed (just 4%
of children were below his score). The processing speed tasks in WIAS II are similar topassage reading because both need continuous visual tracking and thus a convergence ofboth eyes. Clearly, NT was still poor in this skill. NT needed extra support to help him faceexams in high school (grades 8 to 12). He received a comprehensive report which was thenused to win for him extra time during exams. The table below summarizes how his scores
improved with 70% extra time.
Task

15 min timed test

With extended time

English language
questions••

Completed 50% of test
Performance at 57%.

••

Needed 10 minutes extra
Performance now at 70%.

Analytical-logicalquestions••

Completed 50% of test
Performance at 43%.

••

Needed 12 minutes extra
Performance now at 90%.

NT will continue needing help beyond school, whether he attends university or other further
education institution. Educational courses have critical activities in which a student mustshow competence. NT would do well to choose a higher education course – ideally one
which draws upon his interests and aptitudes but is not particularly dependent on visualtracking and high quality convergence. He will also need to plan his study time in such a waythat he is not reading (or performing other eye coordination activities) for a long time because
this will compound his eye fatigue and slow him down. Finally, he would benefit from extra
time for exams, especially when a lot of writing is required.

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IACAPAP Textbook of Child and Adolescent Mental Health2002). It follows then that the nature of the sensory deficit and the methods ofmanagement of the primary sensory impairment can have long term implications
on literacy acquisition, and school underachievement.
Summary•

Not all children who present with poor school attainment will haveprimary learning difficulties. Differential diagnosis is important sincelearning difficulties may be a symptom of another psychiatric disorder orof a sensory impairment.

•

In some countries, school systems have arrangements in place which makeallowances for children’s learning difficulties and additional needs. Thesemay include extra time during formal assessments, the use of scribes,
ability to drop a second and third language in school and to study asimpler course.

•

These concessions in the curriculum and for school examinations aremeant to ensure that scholastic achievement of children with special
educational needs are as close to their true potential as possible.

•

Often these provisions are made available to some or all of the following
areas of difficulty: sensory impairments, developmental disorders,emotional and behavioral disorders and neurological difficulties.

•

These provisions are, however, rarely made available to children withtransient adjustment difficulties, victims of natural disasters, or othertraumatic situations such as war and civic strife.

CONCLUDING COMMENTS
Classification•

Categories of developmental disorder are underpinned by dimensions andassociated “risk factors”•

Dyslexia is a dimensional impairment even though it is often discussed as adiagnostic “entity” with clear-cut boundaries•

Dimensional impairments interact during development to produce
heterogeneity within and between disorders•

The reliability of cross-sectional indicators may be less than of longitudinal
indicators. It is better to recruit all low performing children into adaptedinterventions and then to monitor their response to the intervention. Thosenot catching up to grade level in spite of individualized support would be theones most reliably diagnosed as with SLD•

Language-based measures, more than intelligence and general processing
measures, are better predictors of later literacy difficulties•

There is a need for context-specific assessment tools that are not merely atranslation from tools developed elsewhere. Indeed, blind translation of
screening tools can seriously mislead diagnosis.

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IACAPAP Textbook of Child and Adolescent Mental Health•

Language and phonological skills may be taken as the foundation skills forliteracy development. When skill and sub-skills in either one of these domains
are selectively impaired “compensation” is possible. But the more severe theimpairment and the greater the number of sub-skills that are impaired, themore severe will be the literacy difficulty. The profile of difficulty will either
be one of dyslexia or a reading comprehension difficulty or a mix of both•

Two aspects of current child development research – resilience and social
ecology – have influenced current understanding of what may be the bestpractices for children in need. Both of these socio-emotional constructs
remain crucial in any evaluation and intervention process that have been
set up for children with school underachievement and specific learning
difficulties.

Instruction•

Quality of instruction in mainstream classrooms decides how many children
will fall behind. Thus, with poor quality instruction many more children will
fall below a cut-off of attainments•

For many children showing early difficulties, supplementary input andadapted programs can help resolve difficulties. For older children and later
emerging difficulties, remedial programs can help•

Quality of instruction in remedial programs also decides how many children
will respond to intervention. With poor quality remediation, the preventativerole of interventions will be minimal•

Some patterns are visible in the occurrence of co-morbidities between literacy
difficulties and other disorders. It is essential to more fully understand theseco-occurring difficulties and their implication for instructional programs•

When interventions to promote reading or language are based on atheoretically valid framework this can be effective•

Targeted interventions need to focus on the dimensions that underpin literacy
difficulties (broader oral language and phonology).

What to invest in?
•

A preventative approach rather than a curative approach. Hence, prioritize
quality-first teaching for all, early identification of children whose
development is delayed, interventions for children showing mild difficulties
which may increase if left unattended and interventions that address themultiple foundations for learning•

Screening tools. For literacy difficulties, measures related to language andreading; for math, measures related to reading and number skills•

Formats for determining risk status. This is an arbitrary cut-off and may, forexample, be any child below the 50% mark for the grade. If there are several
children with low attainments, choose a whole class and mainstream an

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One language is neverenoughTo see this sentence written
in many of the scripts of theworld click on the picture.

41

IACAPAP Textbook of Child and Adolescent Mental Healthintensive program•

An intensive whole class program. This is not just for the nurturance needed for
all children but also because classification is easier if we know that children
have received quality intervention and in spite of that they are still struggling•

Decide on which group will be prioritized for support. For example, focus could
be on children who are on the borderline of underachievement and who
will respond to intervention and quickly move out of the “at risk” status.
Alternatively, priority could be given to those who are substantially behind
and who appear to have long term reading difficulties•

Format for determining diagnosis. Mix response to intervention approacheswith approaches that depend on discrepancy criteria for diagnosis. Thus if
the child remains below grade and age level despite intervention and if thechild’s cognitive profile is below his peers, then confirm diagnosis of a generallearning difficulty (having discounted emotional or behavioral problems)•

Develop a nuanced picture of the social and environmental context. This isimportant, particularly to understand the role of local social deprivation andits impact on attainment in literacy and language.

William-Adolphe Bouguereau(1825-1905) La leçon
difficile (The Difficult Lesson)
Wikimedia CommonsSpecific learning difficulties

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IACAPAP Textbook of Child and Adolescent Mental Health

REFERENCES
Abu-Rabia SD & Mansour (2003). Word recognition andbasic cognitive processes among reading-disabled
and normal readers in Arabic. Reading and Writing,
16:423-442.

Leybaert J (2005). Learning to read with a hearing impairment.
In MJ Snowling, C Hulme (eds), The Science ofReading: A Handbook, Oxford, UK: Blackwell: 379396.

Bishop DVM, Whitehouse AJO, Watt HJ et al (2008). Autism
and diagnostic substitution: evidence from a studyof adults with a history of developmental language
disorder. Developmental Medicine & Child Neurology,
50:341-5.

McBride-Chang C, Chow BW-Y, Zhong Y-P et al (2005).
Chinese character acquisition and visual skills in two
Chinese scripts. Reading and Writing, 18:99-128.

Bohman TM, Bedore LM, Peña ED et al (2010). What you hear
and what you say: Language performance in Spanish
English bilinguals. International Journal Bilingual
Education and Bilingualism, 13:325-344.
Bundy D, Joshi A, Rowlands M et al (2003). Envisioning
Education in Low Income Countries. Washington, DC:
The World Bank.
Chen HC, Yamauchi T, Tamaoka K et al (2007). Homophonicand semantic priming of Japanese Kanji words: a timecourse study. Psychonomic Bulletin & Review, 14:6469.
Chen X, Hao M, Geva E et al (2009). The role of compoundawareness in Chinese children’s vocabulary acquisitionand character reading. Reading and Writing, 22:615631.

Chondrogianni V, Marinis T (2011). Production andprocessing asymmetries in the acquisitionof tense morphology by sequential bilingual
children. Bilingualism: Language and Cognition,
pp1-17.
Chow BW-Y, Ho CS-H, Wong SW-L et al (2011). Genetic
and environmental influences on Chinese language
and reading abilities. PLoS ONE 6(2): e16640.
doi:10.1371/journal.pone.0016640
Durkin MS, Schneider H, Pathania VS et al (2005). Learningand Developmental Disabilities. In DT Jamison,
JG Breman, AR Measham et al (eds) Learning andDevelopmental Disabilities, Disease Control Priorities in
Developing Countries. Washington: Oxford University
Press, pp933-951.
Goodman R (1997). The Strengths and Difficulties
Questionnaire: A research note. Journal of Child
Psychology and Psychiatry, 38:581-586.
Hackett R, Hackett L, Bakta P et al (1999). The prevalence
and association of psychiatric disorders in children in
Kerala, South India. Journal of Child Psychology andPsychiatry, 40:801-807.
Hannum E, Zhang Y (2008). Poverty and proximate barriers
to learning: Vision deficiencies, vision correctionand educational outcomes in rural Northwest China.
PARC Working Paper Series, WPS 08-05.

Muter V, Hulme C, Snowling MJ et al (2004). Phonemes, rimes,
vocabulary, and grammatical skills as foundationsof early reading development: Evidence from alongitudinal study. Developmental Psychology, 40:665681.
NAPE (1999-2008). Report of the National Assessment of Progressin Education, Uganda National Examinations Board.
Annual executive summaries.
Nag S, Arulmani G (2006). Handbook for Prevention of Child
Labour for Village Community Workers (English edition),International Labour Office (ILO), Geneva.

Nag S (2007). Early reading in Kannada: the pace ofacquisition of orthographic knowledge andphonemic awareness. Journal of Research in
Reading, 30:7–22.
Nag S, Snowling MJ (2011). Reading comprehension, decoding
skills and oral language. The EFL Journal, 2:85-105.
Nag S, Snowling MJ (2011). Cognitive profiles of poor readersof Kannada. Reading and Writing, 24:657-676.
Nielsen DC, Luetke-Stahlman B (2002). Phonologicalawareness: One key to the reading proficiency of deaf
children. American Annals of Deaf, 147:11-19.
Oller DK, Pearson B, Cobo-Lewis AB (2007). Profile effects
in early bilingual language and literacy. Applied
Psycholinguistics, 28:191-230.
Pennington BF (2006). From single to multiple deficit models ofdevelopmental disorders. Cognition, 101:385-413.
Pennington BF, Olson R (2005). Genetics of dyslexia. In MJ
Snowling, C Hulme (eds), The Science of Reading: A
Handbook, Oxford, UK: Blackwell: 379-396.
Rao C, Vaid J, Srinivasan N et al (2011). Orthographic
characteristics speed Hindi word naming but slow
Urdu naming: evidence from Hindi/Urdu illiterates.
Reading and Writing, 24:679-695.
Richlan F, Kronbichler M, Wimmer H (2011). Meta-analyzing
brain dysfunctions in dyslexic children and adults.
Neuroimage, 56:1735-1742.
Sénéchal M, LeFevre J (2002). Parental involvement in thedevelopment of children’s reading skill: A 5-year
longitudinal study. Child Development, 73:445-460.
Shaywitz S. Current concepts: Dyslexia. New England Journal of
Medicine, 338:307-312.

Ho CS-H, Chan DW-O, Tsang S-M et al (2002). The cognitive
profile and multi-deficit hypothesis in Chinese
developmental dyslexia. Developmental Psychology,
3:543-553.

Seymour PHK (2005). Early reading development in European
Orthographies. In MJ Snowling, C Hulme (eds),
The Science of Reading: A Handbook, Oxford, UK:
Blackwell: 296 – 315.

Hulme C, Snowling MJ (2009). Developmental Disorders of
Language, Learning and Cognition. Oxford: John
Wiley & Sons.

Snowling MJ (2008). Specific disorders and broader phenotypes:
The case of dyslexia. Quarterly Journal of Experimental
Psychology, 61:142-156.

Specific learning difficulties

C.3

43

IACAPAP Textbook of Child and Adolescent Mental Health

Srinath S, Girimaji SC, Gururaj G et al (2005). Epidemiologicalstudy of child and adolescent psychiatric disorders inurban and rural areas of Bangalore. Indian Journal of
Medical Research, 122: 67-79.
Tong X, McBride-Chang C, Wong AM-Y et al (2011).
Longitudinal predictors of very early Chinese literacy
acquisition. Journal of Research in Reading, 34:315332.
Tong X, McBridge-Chang C (2010). Developmental modelsof learning to read Chinese words. Developmental
Psychology, 46:1662–1676.
UNEB 2008. The Achievements of Primary School Pupils in
Uganda in Numeracy and Literacy in English. Reportof the National Assessment of Progress in Education,
Uganda National Examinations Board.
Vasanta D (2007). Phonological awareness and literacy
acquisition in Telugu-speaking, normal hearing andhearing-impaired children. Contemporary Education
Dialogue, 4:217-237.

Vellutino FR (1979). Dyslexia: Research and Theory. The MIT
Press.
Vellutino FR, Fletcher JM, Snowling MJ et al (2004). Specificreading disability (dyslexia): What have we learnedin the past four decades? Journal of Child Psychology &Psychiatry, 45:2-40.
Vellutino FR, Scanlon DM, Zhang H et al (2008). Using
response to kindergarten and first grade intervention
to identify at risk children for long term reading
difficulties. Reading and Writing 21:437-480.
Verhoeven L (2000). Components in early second language
reading and spelling. Scientific Studies of Reading,
4:313-330.

Wydell TN (2003). On the reading process in cognitive
neuropsycholinguistics. Japanese Journal of
Learning Disabilities, 12:248-256.

Paul Mlangasi, a blind teacher, explains a passage in Braille to a young boy at the Wilson Carlile schoolfor blind children at Buigiri, near Dodoma, Central Province, Tanzania. The National Archives UK.

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