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- Indian J Psychol Med
- v.45(3); 2023 May
- PMC10159575
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Indian J Psychol Med. 2023 May; 45(3): 213–219.
Published online 2022 Jun 26. doi:10.1177/02537176221100128
PMCID: PMC10159575
PMID: 37152385
Liss Maria Scaria,1 Deepa Bhaskaran,
1 and Babu George1
Author information Copyright and License information PMC Disclaimer
Abstract
Background:
Specific learning disorders (SLD) comprise varied conditions with ongoingproblems in one of the three areas of educational skills–reading, writing,and arithmetic–which are essential for the learning process. There is adearth of systematic reviews focused exclusively on the prevalence of SLD inIndia. Hence, this study was done to estimate the prevalence of SLD inIndian children.
Methods:
A systematic search of electronic databases of MEDLINE, Embase, PsycINFO, andCINAHL was conducted. Two authors independently assessed the eligibility ofthe full-text articles. The third author reassessed all selected studies. Astandardized data extraction form was developed and piloted. The pooledprevalence of SLDs was estimated from the reported prevalence of eligiblestudies, using the random-effects model.
Results:
Six studies of the systematic review included the diagnostic screening of8133 children. The random-effects meta-analysis showed that the overallpooled prevalence of SLD in India was 8% (95% CI = 4–11). The tools used todiagnose SLD in the studies were the National Institute of Mental Health andNeurosciences (NIMHANS)-SLD index and the Grade Level Assessment Device(GLAD).
Conclusions:
Nearly 8% of children up to 19 years have SLD. There are only a fewhigh-quality, methodologically sound, population-based epidemiologicalstudies on this topic. There is a pressing need to have largepopulation-based surveys in India, using appropriate screening anddiagnostic tools. Constructing standardized assessment tools, keeping inview the diversity of Indian culture, is also necessary.
Keywords: Specific learning disorders, prevalence, India, systematic review, meta-analysis
Specific learning disorders (SLD), often referred to as learning disability, is aneurodevelopmental disorder (NDD) and refers to ongoing problems in one of the threebasic skills–reading, writing, and arithmetic–which are the essential requisites for thelearning process.1 These difficulties, namely dyslexia, dysgraphia, dyscalculia, dyspraxia, anddevelopmental aphasia,2 can occur alone or in different combinations ranging from mild to severe difficulties.3
Dyslexia, the reading disability, is the most common condition, accounting for about 80%of all SLDs.4 Dysgraphia is generally characterized by distorted writing despite thoroughinstructions. The significant characteristic of dyscalculia is the problems inunderstanding or learning mathematical calculations. About 30% of children with SLD havebehavioral and emotional problems, and they are at increased risk for hyperactivity andother comorbidities.5
Although SLD cannot be cured, there are interventions for underlying conditions so thatchildren with SLD can adapt, accomplish academic achievements, and live productive andfulfilling lives.3Diagnostic and Statistical Manual of Mental Disorders (DSM-5)estimates the prevalence of all learning disorders (including impairment in writing,reading, and mathematics) to be about 5% to 15% worldwide.6 The lifetime prevalence of learning disability among children in the USA was 9.7%.7 In India, the prevalence of SLD is reported to vary from 3% to 10%.8
In India, although SLD is included as one of the disabilities according to the Rights ofPersons with Disability Act of 2016, the screening and diagnosis of SLD are complicated.Various tools are used for the assessment, with their own merits and demerits. Sometools like the AIIMS SLD: comprehensive diagnostic battery9 and the National Institute of Mental Health and Neurosciences (NIMHANS) index for SLD10 are commonly used for assessment, but there is a dearth of well-established normsfor the subtypes of SLD. There is no screening tool available for teachers to identifySLD, and various education boards (central and state boards) have different levels ofacademic curriculum. Some tools like the NIMHANS index for SLD can only be administeredin English-medium schools, whereas in India, about 42% of students are studying inHindi-medium schools.11 Although many tools are developed in regional languages like Tamil, Kannada, and Marathi,12 there is no nationwide acceptability of these tools to certify children withSLD.
It is crucial to have a review to know the depth and breadth of the problem and thedifferences in the diagnostic criteria used in the studies. There is a lacuna in theevidence regarding the prevalence of SLDs, and usually, they go undetected.13,14 Early diagnosis and assistancefor a child with SLD is the need of the hour, and thus it is also essential to knowabout the diagnostic methods used. There is a lack of systematic reviews focusedexclusively on the prevalence of SLD in India. Estimating the prevalence of SLD in Indiais valuable in planning diagnostic and intervention services. Information regarding theoverall estimate of SLDs in the country will help develop a school-based policy forearly identification, referral, and management of children with SLDs. Hence, this studywas designed to perform a systematic review and meta-analysis to estimate the prevalenceof SLD in Indian children and review the tools used for diagnosing SLD.
Materials and Methods
The protocol for the review was registered with PROSPERO (registration number-CRD42020154690).
Data Sources and Search Strategy
Two investigators (LMS and DB) searched the electronic databases of MEDLINE,Embase, PsycINFO, and CINAHL. Data search was carried out between June andAugust 2021. Because SLD prevalence studies were published since 1990, theauthors selected 30 years to review articles (1990–2020). Additional searcheswere conducted in Google Scholar and grey literature sources such as documentsof conferences and government websites. Hand searching and retrospectivesearching of relevant published literature was also done. All English-languagestudies containing information on SLD prevalence among children and adolescentsaged 6 to 19 years were retrieved. To select the upper age limit, the WHOdefinition of adolescents as 10 to 19 years was adopted.15 From the selected studies having information on the prevalence of SLD,information on screening criteria and tools used to diagnose SLD was identifiedand reviewed. A search strategy that included the combination of subject termsand free-text terms was employed using the operators “OR” and “AND.” The MedicalSubject Headings (MeSH) terms were SLD, learning disability, learning disorder,dyslexia, dysgraphia, dyscalculia, prevalence, and India. All MeSH terms wereexploded where necessary (Table 1).
Table 1.
Search Strategy Used in MEDLINE Database (1989-2020)
| Number | Search Terms |
| 1 | prevalence/or incidence/or prevalence [MeSH Terms]/orprevalence* |
| 2 | AND |
| 3 | learning disability/or learning disabilities/or learningdisorder [MeSH Terms] or learning disorder*/or dyslexia[MeSH Terms]/or dysgraphia [MeSH Terms]/or dyscalculia [MeSHTerms] |
| 4 | AND |
| 5 | children/OR child*/or child aged less than 18 years |
| 6 | AND |
| 7 | India/OR Indian/OR Indian studies |
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Population
The population of interest was school-going children residing in India aged 6 to19 years who were assessed for SLD using different existing tools for diagnosingSLD.
Inclusion Criteria
Observational studies, including cross-sectional, cohort, or case-controlstudies, of children with SLDs, using validated or nonvalidated tools, publishedin the English language and conducted in community settings, were included.Where multiple publications were generated from the same data with the sameoutcome, only the most relevant study was included.
Exclusion Criteria
Studies that discussed therapy, management, and comorbidities of SLDs wereexcluded. Studies conducted in hospitals were excluded because the children arelikely to be highly selected (i.e., selection bias), resulting in inaccurateestimations of the true prevalence of SLDs. Studies were excluded if childrenwere not screened for intelligence quotient (IQ). Editorials, letters, opinionarticles, narrative or systematic reviews, brief communications, and posterswere excluded.
Screening Strategy
Two authors reviewed the titles and/or abstracts of studies identified using thesearch strategy and those from additional sources. They independently assessedthe eligibility of the full-text articles. The third author (BG) reassessed allselected studies. Any disagreement between the reviewers was resolved throughdiscussion with the third author.
Quality Analysis
The quality of reporting in the selected articles was checked using Strengtheningthe Reporting of Observational Studies in Epidemiology (STROBE). The STROBEchecklist for cross-sectional studies was used to evaluate the relevantinformation from each article. LMS and DB independently assessed studies’reporting quality. In case of any disagreement on this assessment, the issue wasresolved by discussion or consensus with the third investigator (BG).
Data Extraction
A standardized data extraction form was developed and piloted based on theCochrane good practice data extraction form template to extract data from theselected studies. Extracted information included study design and methods, studysettings, participant characteristics, study outcomes, results, conclusions, andstudy funding sources.
The pooled prevalence of SLDs was estimated from the reported prevalence ofeligible studies, using the random-effects model. Analyses were performed usingSTATA 16 (College Station, Texas, USA) software. Forest plots were generateddisplaying prevalence with the corresponding 95% confidence intervals(asymptotic Wald) for each study. The I-squared (I2) test was used to assessheterogeneity. The tools used to diagnose SLD were identified from the selectedarticles and reviewed.
Results
Literature Search
The preferred reporting items for systematic reviews and meta-analyses (PRISMA)statement flowchart16 in Figure 1describes the literature screening, study selection, and reasons for exclusion.Out of 17 studies assessed for eligibility, 11 were excluded for the followingreasons: management/interventional/risk factor studies,17,18 nodiagnosis done/only screened for different SLDs,19–22 the prevalence of SLD wasnot assessed,23,24 the study did not screen for the intelligence of theparticipant children,25 and studies assessed only dyslexia.26,27 A total of six studiesmet the inclusion criteria for this review and were finally included in themeta-analysis (Table2).28–33
Figure 1.
PRISMA Flow Diagram of the Review Process and Study Selection
Table 2.
Characteristics of Selected Studies
| Author | Year | Region | Study Setting | Age in Years | Number of Children with SLD | Total Number of Children Surveyed | Male Female Ratio | SLD Studied |
| Mogasale et al. | 2012 | Belgaum, Karnataka | School | 8–11 | 165 | 1088 | 1.69 | SLD–total and Dyslexia Dysgraphia Dyscalculia |
| Arun et al. | 2013 | Chandigarh | School | 12–19 | 38 | 2402 | 1.33 | SLD–total |
| Arora et al. | 2018 | Himachal Pradesh, Haryana, Odisha, Andhra Pradesh, Goa | Community | 6–9 | 32 | 1970 | 1.01 | SLD–total |
| Sharma et al. | 2018 | Gwalior, Madhya Pradesh | School | NA (third –sixth standard) | 23 | 800 | 0.97 | SLD–total and Dyslexia Dysgraphia Dyscalculia |
| Shah and Buch | 2019 | Jamnagar city, Gujarat | School | 7–12 | 38 | 393 | 0.87 | SLD–total and Dyslexia Dysgraphia Dyscalculia |
| Chacko and Vidhukumar | 2020 | Ernakulam, Kerala | School | 8–12 | 244 | 1480 | 1.03 | SLD–total |
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SLD, specific learning disorders.
Description of Included Studies
The studies included in this review were conducted in different states of India,including Andhra Pradesh, Chandigarh, Goa, Gujarat, Haryana, Himachal Pradesh,Karnataka, Kerala, Madhya Pradesh, and Odisha. All were cross-sectional studiesdone among children aged 6 to 19 years. The studies assessed children at ayounger age itself, except for Arun et al., for which the age group was 12 to 19years. Three studies assessed the subcategories of SLD separately along with thetotal prevalence of SLD31–33; all other studies assessed SLD in total and not thesubtypes. The study by Arora et al. was done in the community setting,29 and all the other studies were conducted at schools. Of the studiesconducted in schools, the study setting of four included both private andgovernment schools. Three studies were conducted in urban areas alone.31–33 The gradein which the students were studying ranged from Class II to Class XII. Thearticles by Mogasale et al., Sharma et al., and Shah and Buch assessed studentsof Classes III to IV, III to IV, and II to VI, respectively.31–33
SLD was diagnosed with different diagnostic tools in different studies. The toolsused to screen and diagnose SLD were the NIMHANS-SLD index and Grade LevelAssessment Device (GLAD34; Table 3).All the studies except Arora et al. used the NIMHANS-SLD index to diagnose SLD.The tool is available for English-medium students, and while using this tool,the authors used local language textbooks of lower grades for assessments.
Table 3.
Methodological Details of Specific Learning Disorders’ Screening andEvaluation Done
| Criteria | Mogasale et al. | Arun et al. | Arora et al. | Sharma et al. | Shah and Buch | Chacko and Vidhukumar |
| IQ test | Yes | Yes | Yes | Yes | Yes | Yes |
| Hearing test | Yes | Not mentioned | Yes | Yes | Yes | Yes |
| Vision assessment | Yes | Not mentioned | Yes | Yes | Yes | Yes |
| Other NDDs excluded | Yes | ADHD not excluded | Yes | Yes | Yes | Locomotor impairment |
| Diagnostic measure | NIMHANS index | NIMHANS index | GLAD | NIMHANS index | NIMHANS index | NIMHANS index |
| Case ascertainment | Screened by pediatric postgraduates diagnosed by a clinicalpsychologist | Screening by teachers based on a six-item proforma diagnosedby psychologist | The diagnostic team comprised a physician,audiologist/speech therapist, and psychologist | Initial screening using academic performance screened forvision and hearing from the pediatric outpatientdepartment | Team of developmental pediatricians, special educators,and psychologists | Screened by parents or teachers using a learning disorderscreening tool diagnosed by a psychiatrist |
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NDDs, neurodevelopmental disorders; ADHD, attention deficit hyperactivitydisorder; GLAD, grade level assessment device; NIMHANS index, NationalInstitute of Mental Health and Neurosciences index for SLD; SLD,specific learning disorders; IQ, intelligence quotient.
The highest prevalence rate of SLD from individual studies was reported as 16.49%by Chacko and Vidhukumar,30 followed by Mogasale et al., who reported a prevalence rate of 15.17%.31 The least prevalence was reported as 1.58% by Arun et al.28 Mogasale et al. reported 12.5%, 11.2%, and 10.5% prevalence ofdysgraphia, dyslexia, and dyscalculia, respectively,31 while the prevalence of SLD subtypes–dysgraphia, dyslexia, anddyscalculia–reported by Shan and Buch was 7.4%, 8.6%, and 7.1%, respectively.32
The six studies of this systematic review have included the diagnostic screeningof 8133 children. The random-effects meta-analysis showed that the overallpooled prevalence of SLD in India was 8% (95% CI = 4–11, Figure 2). In this meta-analysis, a highlevel of heterogeneity (98.72%) was observed between the studies. The diamond inthe result represents the point estimate of 7.7% from all the individual studiestogether. The horizontal point of the diamond represents the 95% confidenceinterval of this combined point estimate.
Figure 2.
Prevalence of Specific Learning Disorders Among Children Aged 6 to 19Years in India (Random Effect Model)
Subgroup analysis and meta-regression were not attempted because the studies didnot mention urban-rural differences or gender differences. Also, characteristicssuch as age group, type of study, and the diagnostic measure did not vary muchamong the studies.
In this meta-analysis, because the outcome measure is the prevalence and theprobability that significance levels that may have biased publications are less,publication bias may not be applicable. The reasons for nonpublication are morelikely small studies not using appropriate methodology. All the selectedarticles satisfied the STROBE criteria for reporting.
Discussion
This systematic review reports an 8% prevalence of SLD in India. All the enrolledstudies were recently published from 2012 to 2020. However, the six studies includedin this review used a spectrum of tools for screening and diagnosis of SLD.
There is no single screening and diagnostic tool that may be considered specific forthe diagnosis of SLD. The NIMHANS index for SLD was developed in 1991 in theDepartment of Clinical Psychology, NIMHANS, Bangalore. The NIMHANS index for SLD isa curriculum-based assessment that can be used to confirm the diagnosis of SLD.10 It includes tests of reading, writing, spelling, and arithmetic abilities todetect children with disabilities in these areas. There are norms for children inStandards I to V. This battery can be used not only for confirming an initialdiagnosis of SLD but also for certification of SLD in India. The Gazette of India(No. 61, dated January 6, 2018) states that the NIMHANS-SLD index shall be used todiagnose SLD in children. The tool can also be used for the assessment ofimprovement after remediation. However, the different types of SLDs cannot be pickedup using this battery.35 Besides, since the tool is in English and India is a multilingual country,professionals find it challenging to assess SLD in a child’s mother tongue.
The assessment using GLAD includes the level of functioning and process of learning.In developing this tool, the National Council of Educational Research and Training(NCERT)-prescribed minimum levels of learning (MLL) were taken as standard. English,Hindi, and Mathematics textbooks from Class I to Class IV of the Central Board ofSecondary Education (CBSE), Indian Certificate of Secondary Education (ICSE), andthe state board in Andhra Pradesh were used to develop the tool. Items were takenfrom all the syllabi based on the MLL fixed based on NCERT stipulations.34
There is a dearth of acceptable tools that are developed and validated in regionallanguages, particularly in rural parts of the country and the Adivasi population,where the dialects are different. The tools accepted for diagnosis of SLD aredeveloped for students of English-medium schools, whereas in India, only one-fourthof the students study in English-medium schools.36 The content used in the tools is not standardized. Existing tools have notincluded all the age groups for assessment, which makes assessment difficult,especially when the student is to be assessed in tenth or twelfth classes to issue acertificate for availing benefits.37
In a population-based prevalence estimate from the USA, the prevalence of SLDreported was 9.7% in children aged 3 to 17 years.7 Nearly 5% of the US school-age population have learning disabilities thathave been formally identified.38 Our study reports that nearly one in twelve Indian children have SLD. InBrazil, recent estimates show that the prevalence rate was 7.6% for globalimpairment, 5.4% for writing, 6.0% for arithmetic, and 7.5% for reading impairment.39 Also, an epidemiological study from Turkey found the prevalence rate to be 13.6%.40 A recent estimate from Pakistan showed a similar prevalence of 7.7% amongprimary school children.41
SLDs are challenging to diagnose and are often not well understood as a group ofdisorders. There is a gap of nearly four years between the child’s age at SLDdiagnosis and the mother’s first suspicion of a problem.42 The treatment of SLD focuses on educational interventions, and earlyinterventions are most desirable.43 Therefore, it is crucial to identify SLD as soon as possible.
Lack of appropriate resources, tools, and support and lack of awareness among parentsand school teachers are significant issues in the Indian context.44 The multiple curriculums at schools, varying standards, and multilingualismprevent a unifying standardized approach.45 Regional adaptations in protocols and universal screening of children are thevital components. Prospective studies (across different states and vernacularlanguages), multicenter collaborations, and longitudinal research with a largesample and a single comprehensive test battery are needed to understand thesituation better and make the children achieve their maximum potential. Also, SLDepidemiology needs to develop into the arenas of operational research to study theutilization pattern of services as well, thereby making care available to those inneed.
The high prevalence of SLD among children in India implies the need for awarenessgeneration among parents and teachers. Adopting community sensitization programswill be beneficial for early identification and improving access to remedialeducation programs. Advocating and strengthening the integrated education system,management of comorbidities, and prevention of mental health problems will improvethe quality of life of children with SLD.
This systematic review had a few limitations. There was heterogeneity in themethodology among the applied screening and diagnostic tools used in the includedstudies, which might have led to under‑ or over-estimation of the prevalence data.The prevalence rate trend analysis was not done because the studies were publishedrecently within ten years. Subgroup analysis on rural versus urban population andmale and female sex could not be done because the articles did not mention therequired data. Prevalence in the subgroups of ages could not be assessed becausedata were not available for different age groups.
Conclusion
This review systematically analyzed data from Indian studies to determine theprevalence of SLD in India. This is the only systematic review on the topic so far,and it demonstrated that nearly 8% of children have SLD. This may include mild,moderate, and severe cases. The conclusion shall be inferred taking care of thestudy’s limitations. The study also highlights that there are only a fewhigh-quality, population-based epidemiological studies on this topic. This reviewhas contributed to explaining the prevalence estimates of SLD in India. The impactof factors such as urban or rural location, age, diagnostic tools, and medium ofinstructions on SLD prevalence needs to be further investigated. As India is a vastcountry, there is a pressing need to have extensive population-based surveys usingappropriate screening and diagnostic tools. Constructing standardized assessmenttools, keeping in view the diversity of Indian culture, is an enormous task.Similarly, regional-language-based screening and diagnostic tools must be developedfor easy identification and reporting. Since SLD is included as one of thedisabilities in the RPWD Act 2016, diagnosis and certification are warranted. Earlydiagnosis and disability certification are essential requirements for providingequal opportunities, equal rights, and equal participation of the children in thecommunity.
Acknowledgments
We acknowledge the research team of the Child Development Center for their supportduring this study.
Footnotes
The authors have no potential conflicts of interest to declare with respect tothe research, authorship, and/or publication of this article.
Funding: The authors received no financial support for the research, authorship, and/orpublication of this article.
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