Hong Kong Journal of Paediatrics [HK J Paediatr (New Series) 1999;4:133-138]

Home

Current Issue

Evolution

Specific Learning Disabilities (SLD) are problems that have intrigued professionals throughout the years. There are people who believe that SLD only involves problems with reading, while there are those who understand Dyslexia merely as a writing problem with mirror inversion of alphabets. Furthermore, many feel that SLD, although a major and documented problem in Caucasians, may not exist in the Chinese population due to racial and language differences. Yet numerous Hong Kong children and parents suffer daily as a result of this condition with limited recognition and support.

In 1996, the Hong Kong Society of Child Neurology and Developmental Paediatrics (HKCNDP) hosted a meeting on SLD at Queen Elizabeth Hospital with speakers from the medical, psychological and special education sectors. The meeting was well attended by professionals who were convinced of the presence of such problems in our community and agreed that something had to be done. The past two years saw an increase in awareness in the topic in Hong Kong as evidenced by the long list of visiting guests invited by the various organizations to address the subject, and by the growth of a variety of therapies offered for treating the condition, including prism lens, colouredglasses, auditory stimulation, sensory integration and so on. Each claims that his method is superior and poor local parents suffer both losses of time and money in the hope of finding panaceas for their children's problems. While such therapies have public appeal, many cannot be supported by scientific evidence nor theoretical soundness. The lack of unified definitions, local data and cooperation between professionals on management further adds to the confusion.

Sporadically, some activities on the subject have already been started locally. A Study Group on SLD was set up under the Child Assessment Service (CAS) of the Department of Health, Hong Kong Government to study the problem within their service. A Working Group was formed between the Special Education Section of the Education Department and CAS in an attempt to arrive at professional consensus and congruent management practices for children with SLD in Hong Kong. Parent groups such as the Hong Kong Association for SLD was established as self-help organizations with support from various individual professionals. However despite the efforts of these groups and parties, advancement on this issue remains very limited.

Workshop on "SLD: Setting the Scene in Hong Kong"

In November 1998, the Hong Kong Society of Child Neurology and Developmental Paediatrics successfully hosted another meeting on the subject "SLD: Setting the Scene in Hong Kong" whereby speakers from developmental paediatrics and education psychology reviewed the current situation in Hong Kong, addressed the subject conceptually and conveyed the message clearly and forcefully that something needed to be done now. After careful and earnest discussions at the meeting, professionals from over ten disciplines working in this field agreed unanimously on the following:

1) that SLD does exist in Hong Kong in the Chinese race and language

2) that SLD comprises of a heterogeneous group of conditions and that unified definitions are mandatory for meaningful study and management

3) that education rights of children with SLD (as stated by the WHO Declaration of Children's Rights) have to be addressed and respected

4) that a multi-disciplinary working party should be established to tackle the problems in a comprehensive manner, AND

5) that in view of the urgency of the problem in Hong Kong, the approach to this problem should sequentially include immediate measures, long term objectives and the setting up of policies for future practice.

Workshop on "SLD 1999: The Way Ahead"

The workshop on "Specific Learning Disabilities 1999: The Way Ahead" is a continuation on the previous activities. It consisted of a one-day workshop hosted at the Queen Elizabeth Hospital on Tuesday, 2nd March 1999. Two world leading experts on the subject, Dr. Drake Duane (neurologist) and Professor Leong Che Kan (education psychologist and special educator) were invited to address the audience at the Plenary Session on "Overview of the State of Practice and Research in SLD". These successfully set the scene on the subject and the audience was deeply impressed by the speakers' vast experience and the latest development on SLD at the international arena. This was followed by Seminar I on "SLD: Local Experience in Hong Kong" with papers presented by local professionals on the clinical aspects of the subject in relation to Hong Kong. The afternoon session started with Seminar II on "SLD: Current Practice in Hong Kong" where speakers including neurologist, developmental paediatrician, psychologist and educator, administrator, legislator and parent addressed the problem from their respective perspectives. The highlight of the workshop was a Panel Discussion Session on "SLD: The Way Ahead" hosted by speakers from Seminar II together with Dr. Drake Duane, our international expert. During the open forum the following areas were discussed:

1. Understanding of SLD from their professions' perspectives

2. Current practice on SLD within their specialties

3. Measures urgently required to tackle the problems in Hong Kong

4. Proposals for short and long term plans to solve the problems

Through these exchanges and constructive debate, the Panel was able to arrive at preliminary recommendations and practical consensus. Professionals present agreed that joining efforts are mandatory. A document "Resolutions from the Workshop" was adopted at end of the meeting by all professionals present. This will henceforth become a basic reference for all professionals dealing with SLD in Hong Kong. In order to keep the day's important information and discussions on permanent record, the Council of the Hong Kong Society of Child Neurology and Developmental Paediatrics resolved to publish proceedings of the workshop to commemorate this important occasion and for future reference.

Evaluation of Existing Problems facing SLD in Hong Kong

Despite the terms Specific Learning Disabilities (SLD) and Dyslexia been known to Hong Kong for over three decades, they remain a mystery to professionals in the region with most people seeing both terms as referring to problem of inverting alphabets. Over the past five years, through the enthusiastic efforts of the Hong Kong Society of Child Neurology and Developmental Paediatrics, a series of academic activities on the subject were organized through which professional attention was attracted to the topic. These resulted in significant local progress in the understanding of the problem: that SLD and Dyslexia do exist in Hong Kong in the Chinese race and language, and that serious and responsible attitudes as well as a multidisciplinary approach are mandatory for tackling the condition. In view of the urgency of the matter in Hong Kong, the approach to a solution should sequentially include the following areas:

1. Current situation and needs for early action
2. Immediate measures for current problems
3. Long term measures including policies and legislation
4. Government and community input of manpower and resources

1. Current Situation and Needs for Early Attention

1.1 Low awareness of condition in Hong Kong's medical, allied health and education communities.

1.2 Non-uniformity of definitions

1.3 Inadequacy of local data: incidence, characteristics of conditions etc.

1.4 Limited communication between involved professional groups

1.5 A likely significant number of children with undetected learning disabilities in the community

1.6 Inadequacy of local research-supported practice tools and interventional guidelines

2. Immediate Measures for Current Problems

2.1 To establish a theoretically sound set of terms and classification for SLD which is acceptable across professions in Hong Kong. Input from medical neuroscience, psychology, education, psycholinguistics and other specialties are essential in this process.

2.2 To understand the current state of the condition and practice through:

2.2.1 Compiling existing local data on the incidence and nature of SLD for local children

2.2.2 Sharing information on current professional practice used in detection, investigation, evaluation, educational and medical managements etc.

2.2.3 Gathering information on current operational structures, both within individual professionals and departments and between them

2.3 To identify urgently needed measures and tools to identify, evaluate and help children with SLD through the following actions:

2.3.1 Study of current system whereby children with SLD are brought to professional attention

2.3.2 Identification of key areas for improvement for currently available methods of evaluation and diagnosis

2.3.3 Identification of areas where timely, early management (treatment, educational, remediation etc.) are critically needed, and how these can be improved in the short term

2.3.4 Identification of essential points where cooperation is urgently needed between professions and service departments

3. Areas f for or Long Term erm Future Planning

3.1 Professional Aspects

3.1.1 Planning of systematic collection of local epidemiological data

3.1.2 Determination of research directions for assessment tools

3.1.3 Establishment of protocols for intervention, and for measuring progress and intervention effectiveness

3.1.4 Establishment of long term structured definitive channels for professional communication

3.1.5 Identification of training needs for professionals in respective fields, and review of local institutions' role in such training

3.2 For children with SLD and their Families

3.2.1 Promotion of public awareness, correct concepts and acceptance

3.2.2 Promotion of peer support groups for psychosocial support, sharing of information and advocacy

3.2.3 Through professional support, promotion of parental skills in dealing with their children's specific needs

3.3 Policies and Legislations

3.3.1 Review of administrative guidelines for diagnosing SLD and children's access to special help

3.3.2 Review of current structures within the education and medical system which provide remediation and support

3.3.3 Review of sources, diagnostics parameters and logistics through which official data on SLD are compiled

3.3.4 Taking up of an active role in helping government to formulate effective and fair public policy and legislation in relation to these children's right for appropriate educational and therapeutic support

4. Government and Community Input of Resources

Proper recognition of the problem together with appropriate and timely input of manpower, resources and blessing from the government, non-governmental organizations (NGO), institutions and service departments are mandatory and essential for the ultimate success of all aforementioned objectives. Details of the input will be worked out in the course of time

The HKCNDP Working Party on SLD

The Working Party was established by the Council of the Hong Kong Society of Child Neurology and Developmental Paediatrics at the November 1998 Council Meeting with the following terms of reference:

1. to set the scene in SLD for Hong Kong
2. to obtain unified definitions amongst professionals in Hong Kong
3. to study local incidence and relevant statistics
4. to promote communication between local professionals
5. to share experience with overseas experts
6. to establish strategic plans for tackling the problem in Hong Kong

The Structure of the Working Party provisionally will consist of the following:

1. Advisors (local and international)
2. Steering Committee
3. Scientific Committee
4. Policy Committee
5. Action and Publicity Committee
6. Others

Progress

To date, through the dedicated work of Professor Leong Che Kan, Dean of School of Languages in Education, Hong Kong Institute of Education, and Dr. Catherine C. C. Lam, developmental paediatrician with special interest in SLD, the Working Party has already commenced work with satisfactory progress. It is encouraging to report that Dr. Drake Duane (neurologist and leading expert on learning disabilities in the United States) has consented to be our international advisor, and a number of local prominent professionals have promised to serve on the various committees of the Working Party. The Working Party is one of the small yet effective first steps in facing the problem. We are confident that, with the joint efforts of all involved professionals, a brighter future for children with SLD in Hong Kong will materialize very soon!

Conclusion

Urgent problems calling for attention in the management of children with SLD in Hong Kong include low awareness of the condition by Hong Kong's professionals, non-uniformity of definitions, inadequacy of local data on incidence and pattern of the condition, limited communication between involved professional groups, inadequacy of local research-supported practice tools and guidelines, and the presence of under-diagnosed and under-served children in the community. The Workshop on "SLD 1999: The Way Ahead" attempted to solve and alleviate some of these problems. At the least, it has heightened awareness amongst professionals, strengthened communication and tightened the links for future cooperation between professionals. More importantly, this was the first occasion where so many disciplines gathered together in a harmonious environment in search of means to tackle recognized problems in a coordinated manner. "Resolutions from the Workshop" serves to pave the way for a unified definition and to set the direction for future developments.

Amongst the many problems discussed and evaluated at the workshop, one of the key issues to be addressed is the lack of local data. Before well-planned prospective studies are launched hopefully in the near future, currently available tools may be modified through multidisciplinary professional review and parental input for immediate use in early identification and remediation planning. As stressed by professionals and international authorities present, early diagnosis for SLD is essential to allow timely and efficacious intervention. The dilemma between causing social stigmata from wrong labeling and making early diagnosis can be minimized through effective population screening procedures which are based upon valid at-risk warning signs and early predicting factors encompassing developmental trends and life experience factors.

The HKCNDP Working Party on SLD is a wellsupported project which aims to mobilize local professionals in working towards solutions for this subject. Its approach is, sequentially, to identify and ameliorate immediate problems, establish short term objectives and finally to propose long term measures for change. Through working with professionals, legislators, administrators and parents, as well as through enlisting the support of the government and non-governmental organizations, our combined wisdom and strength will surely provide light at the end of the tunnel for all in this difficult mission. All the speakers and participants are to be commended for creating a memorable milestone in the management of children with SLD in Hong Kong. I am confident that, through joint efforts of all concerned, much will be achieved in the coming months, so that at the next Workshop on "SLD in Hong Kong: A Review of our Achievements" to be hosted at the commencement of the next millenium, we shall be able to report on advancements made in SLD management in Hong Kong: a goal which all professionals will look forward to witness!

APPENDIX I

HONG KONG SOCIETY OF CHILD NEUROLOGY
& DEVELOPMENTAL PAEDIATRICS

Workshop on "Specific Learning Disabilities 1999: The Way Ahead"
2nd March 1999, Queen Elizabeth Hospital, Kowloon

"Resolutions from the Workshop"

Resolutions made after a one-day workshop attended by more than 200 experts, both local and overseas, representing more than 20 professional disciplines (including neuroscience, medicine, psychology, education, speech and language, occupational and physiotherapy, administrators, legislators, parents and so on) were officially adopted at the closing of the meeting and witnessed by the international authorities present.

1) SLD exists in all cultures and languages with no evidence to indicate that it is less prevalent in the Chinese population.

2) There is yet no universally accepted definition for SLD but the participants including world experts agreed that the definition should include the following features: It involves

2.1 A heterogeneous group of disorders of constitutional origin

2.2 Specific psychological process deficits causing impairment in corresponding domains of learning. Major forms include dyslexia, specific disabilities in spoken language, specific disabilities in mathematics and non-verbal learning disabilities

2.3 These disabilities may occur alone or co-occur in various combinations

2.4 Specific learning disabilities often exist in spite of adequate intelligence, normal sensory and motor apparatus, and adequate educational opportunity; but could occur concomitantly with other handicapping conditions (sensory impairment, mental impairment, social and emotional disturbance) or extrinsic influences (cultural differences, insufficient or inappropriate instruction), although they are not the results of these conditions

2.5 While problems such as attention deficit disorder are not specific learning disabilities in themselves, they may exist as comorbid conditions in an individual with specific learning disabilities.

2.6 Geographical or professional differences do not lead to differences in the definition

2.7 The "Exclusionary Criteria" are not helpful in delineating what the nature of the disorder is. It results in a group of extremely varied conditions, and cannot contribute to specific intervention prescription nor towards prognostication.

3) Dyslexia is a reading disability and is one of the entities within the heterogeneous group of SLD.

4) Specific appropriate educational intervention is required throughout the child's education.

5) Early detection and intervention are essential in order to maximize intervention effectiveness and minimize secondary problems due to missed opportunities in education and to experiences of failure.

6) The field of SLD belongs to multiple disciplines ranging from neuroscience, medicine, psychology, education, speech and language, occupational and physiotherapy, and so on.

7) Urgent measures are mandatory in Hong Kong to tackle the problems via:

7.1 Study of local incidence and disability pattern

7.2 Immediate measures for current problems

7.3 Long term measures by professionals, children with SLD and their parents, policy-makers and legislators

7.4 Government and community input of manpower and resources.

8) The HKCNDP/Working Party on SLD is a good start for coordinating efforts of all professionals to solve this problem together in Hong Kong.

9) Children with SLD have the right to receive good education (WHO Declaration of Children's Rights).

References

1. Bax M. Specific learning disorders/neurodevelopmental disorders. Dev Med Child Neurol 1999; 41:147.

2. Leong CK, Tamaoka K. Cognitive processing of Chinese characters, words, sentences and Japanese kanji and kana: An introduction. Reading and Writing: an Interdisciplinary Journal, Volume 10 Nos. 3-5 October 1998, 155-64.

3. Lam CCC, Cheung P. Identification and Early Indicators of Specific Learning Disabilities in Hong Kong. J Paediatr Child Health 1997;33(Suppl).

4. Cramer SC, Ellis W. Learning disabilities. Brookes Publishing Co, 1996.

5. Richardson SO. Doctors ask questions about Dyslexia - A review of Medical Research. The Orton Dyslexia Society, 1994.

6. Shaywitz S. Dyslexia. Sci Am 1996:98-104.

7. Bellugi U, Tzeng O, Klima ES, Fok A. Dyslexia: Perspectives From Signs and Script. Reading to Neurons. Cambridge, MA: MIT Press 1989; 137-71.

8. Hynd GW, Semrud-Clikeman M. Dyslexia and Brain Morphology. Psychol Bull 1989; 106(3): 447-82.

9. Tzeng O. Chinese Orthography and Reading: A Clarification. Bird N (Ed). Language and learning. Hong Kong: Institute of Education, Hong Kong Education Department, 1994.

10. Caviness VS, Filipek PA, Kennedy DM. The Neurobiology of Learning Disabilities: Potential Contributions from Magnetic Resonance Imaging. Dyslexia and Development - Neurobiological Aspect of Extra-Ordinary Brains, 1993. Cambridge, MA: Harvard University Press, 257-68.