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Table of Contents
REVIEW ARTICLE
Year : 2022  |  Volume : 19  |  Issue : 2  |  Page : 152-162

Prevalence and pattern of learning disability in India: A systematic review and meta-analysis


1 Assistant Professor, Shri Mata Vaishno Devi College of Nursing, SMVD Narayana Hospital Campus, Katra, Jammu and Kashmir, India
2 Assistant Professor, Shri Mata Vaishno Devi College of Nursing, SMVD Narayana Hospital Campus, Katra, Jammu and Kashmir, India, India

Date of Submission28-Jan-2022
Date of Decision26-Sep-2022
Date of Acceptance27-Sep-2022
Date of Web Publication27-Dec-2022

Correspondence Address:
Prof. Johny Kutty Joseph
Amity University, Gurugram, Haryana. Shri Mata Vaishno Devi College of Nursing, SMVD Narayana Hospital Campus, Kakryal, Katra - 182 320, Jammu and Kashmir
India
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Source of Support: None, Conflict of Interest: None


DOI: 10.4103/iopn.iopn_7_22

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  Abstract 


Introduction: Specific learning disorder (SLD) is a much common concept widely discussed nowadays. Specifically, it is a neurodevelopmental disorder found in children and adults. According to the Diagnostic and Statistical Manual of Mental Disorder (DSM)-V, SLD stands for a group of disorders that impedes the ability to learn or to use the requisite academic skills. It comprises impairment in reading, writing, and mathematical ability. Aim of the Review: This systematic review aimed to identify the prevalence and pattern of learning disability among children of India. Methods: This systematic review and meta-analysis followed the Preferred Reporting Items for Systematic Reviews and Meta-Analyses guidelines and is also registered under PROSPERO vide CRD Number: CRD42021286224. The literature search was done using Boolean operators in databases such as PubMed, ProQuest, Cochrane, ScienceDirect, Google Scholar, and websites such as ResearchGate, Academia, and so on. The literature search was focused on Indian studies conducted between 2000 and 2020 (20 years). The initial search identified 122 articles across the databases. Following the screening process and removing the duplicate files, 20 articles were included in the review. According to the predetermined protocol, the researcher independently searched, reviewed, collected, extracted, and evaluated the requisite data and relevant information from each research article. Each individual research article was assessed for its quality using the “critical appraisal tool for use in systematic reviews addressing questions of prevalence.” In the current review, considering the heterogeneity between the studies with regard to sample selection, geographical location, and instrument used for data collection, a random-effect model was adopted. The statistical evaluations were done through OpenMeta (Analyst). Results and Discussion: The prevalence of learning disability among Indian children ranges from 2.16% to 30.77% across the studies. The pooled prevalence of LD among children and adolescents is estimated to be 10.70% (95% confidence interval [CI]: 7.10% to 14.3%), and the median age was 6–12 years. The prevalence of dyslexia among children and adolescents is estimated to be 6.20% (95% CI: 4.40% to 7.90%; I2 = 97.01% P < 0.001), while the prevalence of dysgraphia is estimated to be 6.30% (95% CI: 3.60% to 9%; I2 = 97.83% P < 0.001). Moreover, the prevalence of dyscalculia is much lower and it is estimated to be 4.90% (95% CI: 2.60% to 7.20%; I2 = 97.59% P < 0.001). The finding of this review is consistent with another review by the National Survey of Children's Health, USA, which estimated the lifelong prevalence of learning disability to be 9.7% in children (USA) from 3 to 17 years of age. Conclusion: The finding of the review explains that learning disability affects quite a large number of Indian Children. The information from the current review may set a benchmark to assess the disease burden of the country and it will be a reference for resource planning and health-care policymaking.

Keywords: Indian scenario of learning disability, learning disability burden in India, prevalence of dyscalculia, prevalence of dysgraphia, prevalence of dyslexia, prevalence of learning disability


How to cite this article:
Joseph JK, Devu BK. Prevalence and pattern of learning disability in India: A systematic review and meta-analysis. Indian J Psy Nsg 2022;19:152-62

How to cite this URL:
Joseph JK, Devu BK. Prevalence and pattern of learning disability in India: A systematic review and meta-analysis. Indian J Psy Nsg [serial online] 2022 [cited 2023 Jan 29];19:152-62. Available from: https://www.ijpn.in/text.asp?2022/19/2/152/365472




  Introduction Top


Specific learning disorder (SLD) is a much more common concept widely discussed nowadays. Specifically, it is a neurodevelopmental disorder found in children and adults. According to the Diagnostic and Statistical Manual of Mental Disorder (DSM)-V, SLD stands for a group of disorders that impedes the ability to learn or to use the requisite academic skills. It comprises impairment in reading, writing, and mathematical ability.[1] Most of the time, learning disabilities can be a lifelong condition, as it affects school, work, personal and family life, social interactions, friendship, play, and so on. Some children may have overlapping learning disabilities of more than one, while some may have a single disability.[2] The children affected with learning disability are usually categorized as children with poor academic ability as they read slowly, skip lines in between reading (while reading aloud), habitual in making mistakes with spelling, illegible handwriting, difficulty in grasping, solving math's problems, and so on.[3] The poor performance due to various learning difficulties affects the academic growth of children creating impairment of the nation's workforce. According to a study conducted in Rajasthan, the prevalence of learning disability is estimated to be 10.25%, with a higher prevalence in males (11.40%) compared to females (7.14%).[3] Another finding from South India reveals a prevalence of 6.6%,[4] while another study from the tribal area of Uttar Pradesh shows a higher prevalence of 30.76%[5] of learning disabilities among children. Although many studies have been conducted across different regions, the country in the past few years on the prevalence and pattern of the burden of learning disabilities, there is much variation in the estimated prevalence across geographical boundaries. It is understood that the learning disability is something that affects the academic life of children, and the National Education Policy 2020 emphasizes the significance of inclusive education.[6] Many schools in India (both private sector and public sector) are either not ready or lack awareness of identifying this phenomenon, which makes timely intervention more difficult. It is learned that early screening and timely interventions help children with these difficulties to grow up in life.[7]

Need for the review

The prevalence of learning disabilities in India ranges from 2.16% to 30.77%. Although we are not clear about the exact etiology behind learning disabilities, it is predisposed that biochemical imbalances, maternal lifestyle, type of pregnancy and childbirth, malnutrition, and developmental anomalies play a vital role in the incidence of these disorders.[8] Furthermore, it was also observed by the investigators that during the past 20 years, a number of observational and case–control studies have been conducted in various parts of the country to find the epidemiological figure of these conditions. A gross variation of the prevalence of various learning disabilities was observed across these researches. The factors that contributed to the heterogeneity of the results included geographical differences, age of the population, the instrument used for diagnosing learning disability, and so on.[9] For instance, the prevalence in Rajasthan was 10.26%, using the screening instruments such as dyslexia assessment questionnaire, Malin's Intelligence Scale for Indian Children (MISIC), and DSM-IV criteria,[3] while its prevalence in Jharkhand, Bihar, Chhattisgarh, and Madhya Pradesh was 30.77%, using the screening instruments such as structured LD screening questionnaire (SQ).[10] Similarly, the prevalence in Pondicherry was 7.5%, using SLD-SQ vision, hearing, and intelligence quotient assessment,[8] and in Himachal Pradesh, Haryana, Odisha, Telangana, and North Goa, it was 4.82%, using different screening instruments such as Linguistic Profile Test, Normative data for children in grades I–V, and Grade Level Assessment Device for children with learning problems in schools by the National Institute of Mental Health Hyderabad.[11] All these figures suggest the gravity of the morbidity burden of learning disability among Indian children. It also signifies the critical importance of early diagnosis of these disabilities so that the sanatory solutions could be recommended to the children and parents.[12] There are many studies conducted in different parts of India to find the prevalence of this significant condition, while no attempt has been made to draw a conclusion on the pooled national prevalence of learning disability in India.[13]

Purpose

This systematic review and meta-analysis aimed to identify the prevalence and morbidity pattern of learning disability among children of India. The focus was to review the available epidemiological and observational studies to find the pooled prevalence learning disability with its morbidity pattern and gender differences.[9]


  Methods Top


This systematic review and meta-analysis followed the Preferred Reporting Items for Systematic Reviews and Meta-Analyses guidelines.[14] The review is also registered under PROSPERO vide CRD Number: CRD42021286224, which is an international database of prospectively registered systematic reviews in health and social care, welfare, public health, education, crime, justice, and international development, where there is a health-related outcome.[15]

Search strategy

We searched the literature using different keywords and combinations of keywords (Boolean operators) in databases such as PubMed, ProQuest, Cochrane, ScienceDirect, Google Scholar, and other sources such as ResearchGate and other direct websites. The search was focused on studies conducted among Indian children within the country. The search was also limited to studies conducted between 2000 and 2020 (20 years). The following search terms were used: learning disability prevalence, dyslexia prevalence, dysgraphia prevalence, dyscalculia prevalence, learning disability burden, epidemiology of learning disability, Indian scenario of learning disability, children, and India. In the second stage, a manual search (supplementary literature search) also was performed on the reference lists of all articles selected during the first search. All the epidemiological and observational studies/survey related to learning disability prevalence were included in the study after considering the inclusion criteria. The entire process was independently completed by two researchers.

Inclusion and exclusion criteria

The inclusion and exclusion criteria were framed to consider the eligibility of the research article to be included in the systematic review and meta-analysis. The inclusion criteria were: (1) original research articles on the prevalence of learning disabilities in general or specified learning disability as classified under DSM-V or -IV among children and adolescents (3–20 years); (2) sample frame shall be general public or school or community environment; (3) cross-sectional or longitudinal or case–control studies; and (4) studies conducted in India between 2000 and 2020 and published/available for free access. The exclusion criteria were: (1) studies that were done in the clinical/hospital/special school setting of and that which does not represent the prevalence of learning disability among the general public; (3) case reports, editorials, and reviews; and (4) studies that did not meet the specified quality as per the critical appraisal tool.[16]

Data extraction

According to the predetermined protocol, two researchers independently searched, reviewed, collected, extracted, and evaluated the requisite data and relevant information from each research article. The inclusion and exclusion strategies were strictly adhered to while reviewing the individual studies. The articles were primarily assessed for duplication as two authors had independently searched and collected the research articles. The data were extracted as per the objectives of the review. Additional significant information was also noted for qualitative synthesis.[9] The data extracted from each research article included details of the authors and journals (only the name of the first author is added in the table), year of publication, geographical location of study (states/union territories of India), research design, sample description, instrument of data collection, prevalence of learning disability (general and specific as per condition classified under DSM-V/IV), and other significant observation. In order to estimate the pooled prevalence, the data from each individual study were analyzed for the age of children, population representation of the sample size, instrument used for diagnosing learning disability, and its gender differences. The disagreements that occurred during the extraction of data were mutually resolved.

Quality assessment of articles included in the review

In the current review, each individual research article study was assessed for its quality using the “critical appraisal tool for use in systematic reviews addressing questions of prevalence.”[16] The instrument comprises nine questions with four standard answer options (yes/no/unclear/not applicable). The overall appraisal is done with three answer options (include/exclude/seek further info), which is based on rater's/researcher's judgment. Each research article was accurately assessed for its quality. All the 20 research articles as listed in [Table 1] were included for meta-analysis after deliberation on its quality and thorough discussion.
Table 1: List of studies included in systematic review and meta-analysis

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Statistical analysis

Prior to the calculation of pooled prevalence and morbidity pattern, the extracted data from each individual study were analyzed for heterogeneity by estimating I2 (tau). The data were organized into the prevalence of learning disability among children and its gender differences. Furthermore, the prevalence of specific learning disabilities such as dyslexia (reading), dysgraphia (writing), and dyscalculia (mathematical/arithmetical) was also estimated. The median age of diagnosis of learning disabilities was also estimated. The details of calculated prevalence with other relevant information are given in [Table 2]. All statistical analyses (meta-analysis) were performed using “OpenMeta (Analyst).”[27] OpenMeta Analyst is a completely open-source, cross-platform software for advanced meta-analysis used for estimating different epidemiological figures. It includes techniques and methods for carrying out different types of meta-analysis in addition to all random-effects and fixed-effects models.[28] The pooled prevalence was estimated by entering the figures under population estimation mode using the input of sample size, number of events/learning disability cases, and adding the lower- and upper-class intervals. In the current review, considering the heterogeneity between the studies with regard to sample selection, geographical location, and instrument used for data collection, a random-effect model was adopted.[27]
Table 2: The distribution of the prevalence of learning disabilities across the studies included in systematic review and meta-analysis with other relevant information

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  Results Top


Totally, 122 studies were initially identified during searching of articles in various databases. Thereafter, the duplicate studies were omitted, and 59 studies were considered potential to be included in the review. Furthermore, the studies were thoroughly analyzed for its originality, availability of desirable data, research methodology and sampling frame selection, inclusion and exclusion criteria, and critical appraisal of the studies according to norms.[16] Twenty (33.9%) studies were included in the systematic review and meta-analysis, and 39 (66.1%) studies were not included considering the insufficiency of data and other factors mentioned above [Figure 1]. All the 20 studies included for the current systematic review and meta-analysis were qualified to be included in the review as per the rater's report obtained through critical appraisal tool.[16] All the studies collected data directly from the children, although four studies sought teachers help in setting the sample frame. All 20 studies reported the prevalence of learning disabilities, while only nine (45%) studies reported the relation between gender and prevalence of learning disabilities. With regard to the prevalence of specific learning disabilities, 14 (70%) studies reported the prevalence of dyslexia, 13 (65%) studies reported the prevalence of dysgraphia, 11 (55%) studies reported the prevalence of dyscalculia, two (10%) studies reported the prevalence of speaking disability, and only one (5%) study reported the prevalence of thinking disability [Table 2]. The point prevalence of learning disability among Indian children ranges from 2.16% to 30.77%. The pooled prevalence of learning disabilities among children and adolescents is 10.70% (95% confidence interval [CI]: 7.10% to 14.3%). The analysis also showed significant heterogeneity among the selected studies (I2 = 99.35%, P < 0.001) [Figure 2].
Figure 1: Flow diagram of included and excluded studies as per the PRISMA 2020 statement.[14] PRISMA: Preferred Reporting Items for Systematic Reviews and Meta-Analyses

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Figure 2: Prevalence of learning disabilities among children and adolescents in India[27]

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With regard to the gender differences in the prevalence of learning disabilities, it was observed that male children showed a pooled prevalence of 13.60% (95% CI: 4.90% to 22.30%; I2 = 99.30%, P < 0.001) [Figure 3], while female children exhibited a lower pooled prevalence, i.e., 8.40% (95% CI: 2.10% to 14.80%; I2 = 99.45%, P < 0.001) [Figure 4]. Furthermore, it is observed across the included studies that gender plays a vital role on the prevalence of learning disabilities.
Figure 3: Prevalence of learning disabilities among male children in India[27]

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Figure 4: Prevalence of learning disabilities among female children in India[27]

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In addition, the pooled prevalence of specific learning disabilities such as dyslexia, dysgraphia, and dyscalculia was also analyzed. The prevalence of dyslexia among children and adolescents is estimated to be 6.20% (95% CI: 4.40% to 7.90%; I2 = 97.01%, P < 0.001) [Figure 5], while the prevalence of dysgraphia is estimated to be 6.30% (95% CI: 3.60% to 9%; I2 = 97.83%, P < 0.001) [Figure 6]. The prevalence of dyslexia and dysgraphia are almost similar. Moreover, the prevalence of dyscalculia is much lower and it is estimated to be 4.90% (95% CI: 2.60% to 7.20%; I2 = 97.59%, P < 0.001) [Figure 7].
Figure 5: Prevalence of dyslexia among children and adolescents in India[27]

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Figure 6: Prevalence of dysgraphia among children and adolescents in India[27]

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Figure 7: Prevalence of dyscalculia among children and adolescents in India[27]

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It is also observed that the median age of screening/diagnosing the learning disability is 6–12 years, i.e., the early years of formal schooling. The significance of birth/delivery-related complications with learning disabilities is noted in two studies.[3],[17] The children with learning disabilities exhibit several behavioral and emotional deviations such as aggression, low self-esteem, hyperactivity, and day dreaming.[19] Although many comorbidities such as fine motor abnormality, neurodevelopmental disorders, developmental delay, anxiety, and depression are observed in children with learning disabilities, attention deficit hyperactivity disorder (ADHD), inattentive type, is found to be the most common comorbidity.[3],[4],[11],[17] The academic difficulties and challenges faced by these affected children include ignoring punctuation and capitals, illegible writing, missing out or misplacing letters or words, frequent spelling mistakes, difficulty in copying from blackboard, and difficulty in flowing instructions.[8],[13],[22] The teachers and parents had significant lack of awareness related to the diagnosis and management of learning disabilities.[17],[20]


  Discussion Top


This systematic review and meta-analysis was aimed at estimating the prevalence and pattern of learning disabilities among Indian children. The point prevalence of learning disabilities found across the included research articles ranges from 2.16% to 30.77%. The pooled prevalence of learning disabilities among Indian children and adolescents is estimated to be 10.70% (95% CI: 7.10% to 14.3%). The current finding is consistent with the prevalence of learning disability among the children of USA, which is estimated to be 2.6% (kindergarten) to 13.2% (5th grade) across the age spectrum ranges.[29] The finding of this review is also in concurrence with another review report from the National Survey of Children's Health, USA, which shows the lifelong prevalence of learning disability to be 9.7% in children from 3 to 17 years of age.[30] Moreover, another provincial survey conducted in Ontario, Canada,[31] found that they have 8.8% of school population who are exceptional and it supports the findings of this review. With regard to specific learning disabilities, our review was focused on dyslexia, dysgraphia, and dyscalculia. It was observed that the prevalence of dyslexia is 6.20% (95% CI: 4.40% to 7.90%; I2 = 97.01% P < 0.001). This finding is in concurrence with the findings of two studies conducted in China, whereas one study[32] estimates the prevalence of dyslexia among children with as 3.9% and the other[33] estimates a prevalence of 5.4% with a higher prevalence among boys. Furthermore, with regard to the prevalence of dysgraphia, it was 6.30% (95% CI: 3.60% to 9%; I2 = 97.83% P < 0.001). The prevalence of dysgraphia estimated in the country through this review is lower than the finding of another study[7] conducted in Telangana, India, which found a prevalence of 15% among children and adolescents. Dyscalculia showed a lower prevalence of dyscalculia, 4.90% (95% CI: 2.60% to 7.20%; I2 = 97.59% P < 0.001). This finding is consistent with the finding of another study conducted in Malaysia,[34] which showed a prevalence of 3.4% of dyscalculia among children and adolescents with a male-to-female ratio of 4:1. Further two studies[2],[11] included in the review estimated the prevalence of speaking disability, which showed a prevalence of 6.25% and 3.20%, respectively, while one of the studies[2] also estimated the extent of thinking disability, i.e., 3.13%.

In relevance to the pattern of learning disabilities among children and adolescents, it is observed that boys showed more prevalence of different learning disabilities compared to female children. The common predisposing/risk factors associated with the incidence of learning disabilities include delivery complications, low birth weight preterm birth, delay in motor development, delay in social development, prematurity, and cesarean section.[3],[4],[17] Another significant observation is related to the comorbidities of specific learning disabilities. Across the included studies, the main comorbidities observed were ADHD, fine motor problems, aggression, hyperactivity, personality problems, neurodevelopmental disorders, autism, cerebral palsy, and epilepsy.[4],[11],[17],[19] The children and adolescents with SLD exhibited following signs and symptoms such as low self-esteem, somatic complaints, anxiety, depression, and aggression, in addition to condition-specific symptoms.[3],[8],[13],[19],[21],[22] It is also observed that the parents and teachers of children with learning disabilities had a significant lack of awareness with regard to the problems faced by the children.[1],[17],[20] Furthermore, it is worth mentioning that the variations in the prevalence of learning disability across the studies included might be due to overestimation or underestimation as the researchers used different scales and instruments to observe the phenomena.


  Conclusion Top


With all these findings and analyses, it is strongly recommended that the National Education Policy 2020 needs to be rightfully implemented across the country as it emphasizes on inclusive education. Although the geographical location of the studies included in the current systematic review is much wider (studies from 15–16 Indian states/union territories have been included in the current review), many states/union territories could not be considered due to the limited availability of quality scientific studies. There is a need to sensitize the school teachers, especially the primary school teachers, regarding the gravity of this phenomenon. Focused training of primary school teachers and parents on early screening and management of children with learning disabilities is the need of the hour to develop an educated nation. The information from the current review may set a benchmark to assess the disease burden of the country, and it will be a reference for resource planning and health-care policymaking.

Limitations

  1. The study is limited to children and adolescents of ages ranging from 2 to 12 years
  2. The studies which are available in different databases on open access is only included
  3. The analysis is based on the data available/published with articles.


Financial support and sponsorship

Nil.

Conflicts of interest

There are no conflicts of interest.



 
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    Figures

  [Figure 1], [Figure 2], [Figure 3], [Figure 4], [Figure 5], [Figure 6], [Figure 7]
 
 
    Tables

  [Table 1], [Table 2]



 

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  In this article
Abstract
Introduction
Methods
Results
Discussion
Conclusion
References
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