Introduction

Specific learning disorder (SLD) is a general term that refers to a heterogeneous group of disorders manifested by significant difficulties in the acquisition and use of listening, speaking, reading, writing, reasoning, or mathematical abilities.1 It affects specific abilities in children with an otherwise normal academic development and with intact senses, normal intelligence, adequate motivation, and sociocultural opportunities.2 Globally, the prevalence of SLD has been estimated to be around 5 to 15%,3 while in India, it affects approximately 0.38 to 15.2% children.4 SLD begins in early childhood and continues across the lifespan with variable clinical expressions.

Children having SLD have been found to be suffering from various psychiatric comorbidities. Attention deficit hyperactivity disorder (ADHD) is the most common comorbid condition with SLD followed by anxiety disorder, mood disorder, and language disorder.5 Many children with SLD can experience low self-esteem, lack of confidence, low expectations for themselves, and poor peer relationship because of their poor learning skills.6 Studies from India have also reported various clinical problems associated with SLD, such as problem with developmental history, behavioral problems, neurotic traits, lower self-esteem, poor social competence, and high-state anxiety, that make management of SLD difficult.7 8 9

Sometimes learning problem contributes and/or triggers the maladaptive behaviors. Failure to achieve expected set targets or achieving lesser than desired outcomes often reflect feelings of isolation and a loss of interest in learning in these children. In addition, repeated failure or poor performance in spite of continuous efforts and practice can be responsible to develop a feeling of learned helplessness. Children may refuse to go to school and may complain somatic symptoms including frequent stomach aches, nausea, vomiting, and headache, to avoid performing on tests of academic skills which further hampers the educational development. In addition, some of them may indulge in disruptive behavior at home and/or classroom, for example, anger outburst and defiant behavior.10 Thus, early recognition and intervention for SLD with psychiatric comorbidities are required to improve outcome. However, only limited studies have paid attention to comorbid condition with SLD which have some methodological limitations. Hence, the present study was planned to examine the associated psychiatric comorbidities in children with SLD.

Materials and Methods

Results

The demographic and clinical profile of the study participants are shown in Table 1. Children with age ranged between 7 and 12 years were participated in the study (mean ± SD = 9.8 ± 1.5). Their classes ranged between 1st and 6th grades (mean ± SD = 5.0 ± 1.5). The sample was constituted primarily of boys (75.6%). Majority of children were belonged to Hindu religion (90.2%), nuclear family (58.5%), and from middle socioeconomic strata (90.2%). All the participants came from an urban background (100%). Majority of the children were born through normal delivery (90%). Only 17.1% of children had birth complication (n = 7) and out of which 4.9% of children had delayed cry (n = 2). Approximately, 24.4% of the participants had delayed milestones (n = 10).

Fig. 1 depicts psychiatric comorbidity in children with SLD where 61% of children exhibited signs of attention deficit disorder (ADD; n = 14), ADHD (n = 9), social anxiety (n = 1), and both oppositional defiant disorder and ADD (n = 1). On Conners 3-Parent Short Form, substantial number of children had elevated scores on inattention (n = 28), hyperactivity (n = 11), executive function (n = 17), aggression (n = 23), and peer relation (n = 24). All children had higher score on learning problems (Fig. 2). Similar to MINI-KID and Conners 3-Parent Short Form, children’s scores obtained on all eight syndrome scales of the CBCL most frequently fell within the clinical range of scale that assessing symptoms of attention/hyperactivity (n = 21). Only one child had a pathological score on the externalizing scale (t-score > 64).

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Fig. 1 Psychiatric comorbidity in children with specific learning disorder on MINI-KID. ADD, attention deficit disorder; ADHD, attention deficit hyperactivity disorder; MINI-KID, Mini-international Neuropsychiatric Interview; ODD, oppositional defiant disorder.

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Fig. 1 Psychiatric comorbidity in children with specific learning disorder on MINI-KID. ADD, attention deficit disorder; ADHD, attention deficit hyperactivity disorder; MINI-KID, Mini-international Neuropsychiatric Interview; ODD, oppositional defiant disorder.

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Fig. 2 Parents’ responses on Conners attention deficit hyperactivity disorder scale.

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Fig. 2 Parents’ responses on Conners attention deficit hyperactivity disorder scale.

Discussion

Associated other psychiatric disorder is very common with neurodevelopmental disorders, including SLD. It is important to have insight about comorbidity with SLD because an additional disorder may affect the expression and severity of the SLD. Learning-disabled children with comorbidity exhibit more severe neurocognitive impairment, negative academic experience, social outcomes, and lower treatment response as compared with children without other comorbid condition.5 Here, we present psychiatric comorbidity evaluation in children with SLD.

The findings emerging from the current study indicate that ADD/ADHD is the most common psychiatric comorbidity with these children. This finding is in line with the previous studies that documented ADHD as the most common comorbid condition with SLD,5 7 17 as high as 45%.18 An Indian study has reported at least 10% of learning disabled children had clinical range of ADHD,19 while another study reported nearly 42% of ADHD.7 However, it was found that relation between dyslexia and inattention symptoms was stronger than to the hyperactive and impulsive symptoms of ADHD.20 In addition, only one child had social anxiety and another child had both oppositional defiant disorder and ADD. As compare with our study, higher prevalence of anxiety disorder and conduct disorder in SLD is reported by earlier studies.5 21 22 This could be due to small sample size and use of different measurement scales in the index study.

On Conners 3-Parent Short Form, along with inattention, hyperactivity, and learning disorder, parents subjectively reported child’s problems related to executive function, peer relationship, and aggressiveness. Researchers have also identified poor motor abilities, psychological process deficits, information processing problems, and attention memory as a core characteristic of SLD.23 Other studies have found deficits in memory, selective attention problem, visual memory, and verbal working memory.24 25 ^Literature is not conclusive regarding learning disability as a cause of aggressive or delinquent behavior; however, limited evidence suggests that reading disability may worsen preexisting aggressive behavior.26 Poor-peer relation and related emotional distress was also observed in our sample. Children had difficulty to form social connection, to getting along with other children, and to execute helpful behavior. This finding is consistent with previous reports mentioning that children with SLD had challenges in reading socioemotional cues, such as not knowing how to ask for help, being awkward in joining peer group, poor organization, planning, and impulse control.10

The findings of the study should be contextualized in terms of the strengths and limitations. The strength of the study includes the evaluation of psychiatric comorbidity in a homogeneous sample for first time, that is, SLD-Mixed type. In addition, we used measures that included self-reporting by parents and clinician’s interview evaluations that were not followed by previous studies. A few important limitations need to be mentioned here. First, though more number of children with SLD included in the study; however, there is still a need for a larger sample to generalize the findings. Another limitation is the conduction of the study at tertiary care center that could not be representative of general population. Different results may be found from a community center and school setups.

Conclusion

This study extends our understanding of psychiatric comorbidities in the children with SLD-mixed type. There was a significant association of SLD with ADD/ADHD along with difficulties in executive function, aggression, and peer relation. The results add crucial points to the existing literature. However, much work is required with a more sophisticated study design. Hence, clinician should pay adequate attention for the evaluation of psychiatric comorbidities in these children. Moreover, our main aim should not be only to get insight about the psychiatric comorbidities and complication associated with SLD but to successfully identify child’s needs that can then be integrated in the management plan which may facilitate effective and holistic improvement in child’s educational and behavioral achievements.