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Year : 2020  |  Volume : 4  |  Issue : 2  |  Page : 126-134

A study of neurological soft signs and potential psychiatric comorbidities in children with specific learning disorders

Department of Psychiatry, Topiwala National Medical College and B.Y.L. Nair Hospital, Mumbai, Maharashtra, India

Date of Submission22-Nov-2019
Date of Decision07-Feb-2020
Date of Acceptance17-Feb-2020
Date of Web Publication24-Sep-2020

Correspondence Address:
Dr. Sayantani Mukherjee
A1-707, Runwal Seagull Township, Handewadi Road, Hadapsar, Pune - 411 028, Maharashtra
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Source of Support: None, Conflict of Interest: None

DOI: 10.4103/aip.aip_81_19

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Context: Children with specific learning disorders (SLD) are often observed with neurological soft signs (NSS) and adjunctive emotional/behavioral symptoms. Aims: This study attempts to quantify both NSS and subclinical psychiatric comorbidities in known SLD cases. Statistically relevant data, if generated, would provide clinicians with a clearer picture and further a more well-rounded treatment plan. Settings and Design: The study was observational, cross-sectional, and quantitative, conducted in learning disability clinic attached to a child psychiatry outpatient department in a public-sector tertiary-care teaching hospital in urban India. One hundred and sixty children of age 7–18 years fitting inclusion criteria were enrolled after appropriate consent/assent. Subjects and Methods: A sociodemographic data pro forma, and two scales, the child behavior checklist and Physical and Neurological Examination for Subtle Signs – Revised (PANESS-R), were used. A single-setting interview was conducted, data collected and statistically analyzed. Statistical Analysis: It was done by a qualified statistician using SPSS-16 software. Results: 36.25% had “total” psychopathology, 41.875% “internalizing problem,” and 30% “externalizing problem,” which were associated with poor interpersonal relations, more physical discipline, and “overflow” component of NSS. On PANESS-R, repetitive speed of movement was the most common. More NSS were found in younger age groups, boys and in association with perinatal maternal age of below 20 and above 30 years. Countering previous findings, right-handed children had high incidence of mixed handedness. Conclusions: We recommend routine screening for NSS and psychopathology in SLD children as these may complicate treatment outcome with secondary psychological/neurodevelopmental issues. Prompt detection and appropriate management might redress them more holistically.

Keywords: Behavior problems, child behavior checklist, neurological soft signs, specific learning disorders

How to cite this article:
Mukherjee S, Sangale J, Shah H. A study of neurological soft signs and potential psychiatric comorbidities in children with specific learning disorders. Ann Indian Psychiatry 2020;4:126-34

How to cite this URL:
Mukherjee S, Sangale J, Shah H. A study of neurological soft signs and potential psychiatric comorbidities in children with specific learning disorders. Ann Indian Psychiatry [serial online] 2020 [cited 2021 Jun 23];4:126-34. Available from: https://www.anip.co.in/text.asp?2020/4/2/126/295909

  Introduction Top

Specific learning disorders (SLD) may engender feelings of nervousness, inadequacy, and shame in the affected children of school-going age, leading to demoralization, poor self-worth, and behavioral disturbances in 30%–80% of them. Alongside, higher association with comorbid child psychiatric disorders such as attention deficit hyperactivity disorder, communication disorders, conduct disorder, mood and anxiety disorders as well as certain motor deficits may complicate the clinical picture further.[1]

SLD as well as these comorbid child psychiatry disorders are postulated to be a part of a common biological etiology, which may be indicated by the presence of neurological soft signs (NSS). NSS is nonlocalizing neurological abnormalities that are neither related impairment of a specific brain region nor are a part of any well-defined neurological syndrome.[2] It is often found that persistence of NSS into later childhood and adolescence suggests atypical neurological development and dysfunction, which serves as a common basis for all these disorders. The relationships between NSS, behavioral problems, and academic under-achievement have been demonstrated in a substantial amount of research.[2],[3]

This motivated the present study, which was undertaken to study hitherto undiagnosed psychopathology and NSS in children having SLD and to correlate these parameters with sociodemographic, developmental, and educational parameters as well as with and with each other. It was conducted in a child psychiatry outpatient department with attached SLD clinic in a public sector tertiary care teaching hospital in cosmopolitan India.

In studying these parameters and their interplay, we hope to gain a better understanding of the SLD population that we were treating, perhaps uncover any missing connections between symptomatology development and outcome, and ultimately implement our findings, if significant, into our day-to-day practice to help these young persons better – perhaps by adding on occupational therapy sessions, involving neurodevelopmental pediatrics into planning therapies for them and offering SLD remediation more customized to the individual child's needs.

  Subjects and Methods Top

The study was observational, cross-sectional, and quantitative. The study was commenced after approval by the Institutional Research Board as well as clearance from the Institutional Ethics Committee.

Setting, subjects, and the interview

The study was conducted in the aforementioned SLD clinic, where 160 consecutive children were recruited. Inclusion criteria were as follows:

  • Assenting children (along with parental consent)
  • Children 7–18 years of age
  • Children had already been certified as SLD through a state government and educational board sanctioned procedure involving history, clinical assessment, intelligence quotient, sensory and neurodevelopmental assessments, specific psychometric assessments for SLD and final certification following the discrepancy model; it is by an experienced multidisciplinary team of psychiatrists, psychologists, special educators, and neurodevelopmental pediatricians. In this process, a general psychiatric evaluation is also done, to diagnose any possible psychiatric comorbidity
  • Children with no major known medical/surgical/neurological/psychiatric comorbidity.

Exclusion criteria were as follows:

  • Children not fitting the age criteria
  • Children having any known major medical/surgical/neurological/psychiatric comorbidity
  • Children not giving assent/parents not giving consent were excluded.

After obtaining written informed consent from parents and assent from children, single interviewer (JS) conducted the interview with the children and their parents in a single setting using the following tools.


The tools of assessment were:

  • Semi-structured pro forma: Created by authors JS and HS for the collection of demographic data. For more detailed evaluation of parenting, disciplining, and relationships, it consists of “yes/no” and “either/or” type of questions. The pro forma was used only after expert validation by two senior psychiatrists and one senior pediatrician with more than 25 years of experience each
  • Two clinical rating scales, used only with necessary permissions:

Child behavior check list

The 2001 adaptation by Achenbach was used, consisting of a 120-item checklist for children of 6–18 years of the age, to be completed by parents, with a 3-point Likert scale of “not true,” “sometime true,” “very true/often true” (0, 1, and 2, respectively).[4] It has a “total” score, with three subscales – “internalizing” (further consisting of “anxious/depressed,” “withdrawn” and “somatic complaints”), “externalizing” (further consisting of “aggressive behaviour” and “delinquent rule-breaking behaviour”), and “other” (further consisting of “attention problems,” “social problems,” “thought problems”).

Each subscale raw score is converted to final standardized percentage score, and the subscale raw scores are totaled and converted to final score for each subscale, and a separate “total” category. The inter-rater and test-retest reliability and internal consistency are 0.93–0.96, 0.95–1, and 0.78–0.97, respectively.

Physical and neurological examination for subtle signs revised

A 21-item observational scale for the examination of NSS in children and adolescents, given by Denckla in 1985, covering gait, stance, laterality, quality of rapid movements, impersistence, involuntary movement, repetitive speed of movement, sequenced speed of movement, and asymmetrical movement.[5],[6] Inter-rater reliability is 0.50, validity is 0.70, and internal consistency is 0.74; it is applicable to children 5 years upward.

To provide a background of physical and neurological examination for subtle signs-revised (PANESS-R), we need to know that NSS components are based on nonnormative performance on a neurological examination of motor and sensory functioning in the absence of a focal lesion. They are poor coordination, speed or accuracy of limb or axial movements (including those required to keep the balance), dysrhythmias, and overflow are often found during the clinical examination of children. They are studied in terms of timed and untimed motor movements. The most reliable of the timed motor movements are “speed of movements” and “dysrhythmias.” Overflow movements are those that are mirrored in other body parts (such as limbs and head) and occur at the same time as in the part(s) intended to perform the movement. They are considered developmentally normal in young children (under 6 years) in whom they persist over time when cortical inhibitory functions fail to develop to stop the radiation of motoric impulses to body parts other than the target body part. They are indicators of delayed development of motor inhibition.

In PANESS-R, for the gait tasks, the examiner scored the number of errors in a sample of 10 steps and recorded the presence of feet-to-hand overflow (i.e., extension of the hand at the wrist during heel walking). For balance tasks, the number of hops (maximum of 50) and seconds standing (maximum of 30 for each foot) was recorded. For repetitive timed movements, the time to complete 20 movements was recorded using a stopwatch, as well as the presence of overflow (proximal, orofacial, and mirror movements) and dysrhythmia. Dysrhythmia was also recorded during hopping. For the motor persistence task, the time that the child could maintain closed eyes was recorded (maximum of 20 s for each stance). The examiner also recorded any abnormal movements (i.e., choreiform movements and limb tremor) seen during the examination. The times for repetitive and patterned movements were converted to z-score based on published normative data. For measures of gait, balance, motor persistence, overflow, dysrhythmia and impersistence, ordinal scores (0, 1, and 2) were given, with higher scores indicating increasing abnormal performance. Ordinal scores were summed across the right and left sides of the body for all measures to create summary scores for the following categories:

  • Gaits: Error scores for heel, toe, sides of feet, and tandem gaits
  • Balance: Error scores for one-footed hops and stands
  • Speed of repetitive timed movements: Z scores were summed
  • Speed of patterned timed movements: Z scores were summed
  • Dysrhythmia: On timed movements
  • Overflow: On gait and timed movements.

For those tests, where no standard scores are defined, the presence of the soft sign above the age of 7 years was taken as abnormal.

Data analysis

The data obtained from the pro forma and scales (regarding sociodemographic profile, psychopathology, self-esteem, and NSS) were tabulated into Microsoft Excel sheets. Statistical analysis was done using statistical software SPSS version 19 (IBM Corp. Released 2010. IBM SPSS Statistics for Windows, Version 19.0. Armonk, NY, USA). Chi-square test (denoted by “χ2”) was applied for finding relationships between child behavior checklist (CBCL) scores and NSS scores with nominal demographic parameters; Mann–Whitney test (denoted by “U”) for relation with CBCL scores, NSS scores, and demographic ordinal variables as well as with each other. The resultant statistics were interpreted with assistance from a qualified statistician.

  Results Top

Observational findings

Sociodemographic profile

About 48.10% of children were in 7–11 years of age group while 51.9% were in 12–18 years of age group. 72.5% were male and 27.5% were female. 80% were right-handed, 18.1% left-handed, and 1.9% showed mixed handedness.

Twenty-six percent had a history of scholastic backwardness in siblings/cousins/parents and 8.33% had siblings already diagnosed with SLD.

In birth and development history, the time of delivery, 3.1% mothers were <20 years of age, and 16% were 30–40 years at the time of delivery. 69.9% children were full-term normal delivery, 23.7% had been delivered full-term by cesarean section, and 3.2% were preterm delivery. 95.5% had immediate cry and 4.5% had delayed cry. 9.4% had delayed motor milestones while 23.3% had delayed speech milestones.

In discipline by parents, mothers were more involved in discipline than fathers and both used mainly verbal mode for disciplining. Fathers use more physical discipline (3.8%) than mothers (2.5%). In interpersonal relationships, 85.6% of children reported having a good relationship with mother followed by that with father (50%), siblings (31.5%), peers (26.9%), and then teachers (20.6%). 15.6% had no friends and 12.5% had one close friend only.

In academics, coming to subject wise performance, almost half of the children had below-average scores as compared to peers (48.8%, 43.8%, 40%, and 42.5% in languages, social studies, mathematics, and science, respectively). Failures were most in languages, followed by science, mathematics, and social studies (43.1%, 36.3%, 35.6%, and 32.5%, respectively). Only 0.6% had above-average performance whereas 38.1% had a history of failing/repeating a grade. 8.8% of children had a history of receiving remedial education either through school or through private resources. 60% of parents perceived it as a major problem, 34.4% found it to be minor problem and 1.9% did not perceive it as a problem. Coming to SLD diagnosis, 85% children had a combination of dyslexia, dyscalculia, and dysgraphia and 15% had dyslexia and dysgraphia.

Psychopathology on child behavior checklist

For interpretation, in each syndrome scale, 93rd–97th percentile is borderline clinical range and above 97th percentile is clinical range. For total, externalizing and internalizing scale score 84th–90th percentile is the borderline range while above 90th percentile is clinical range. The borderline clinical range indicates score high enough to be of concern and in clinical range means problem to be of clinical concern. Hence, our area of concern here is both borderline “B” and clinical group “C” (together termed “B+C”) in total as well as all in the subscales individually.

About 36.25% children displayed significant scores on total category of CBCL. 41.875% of the children had internalized behaviors and 30% of children had externalized behaviors. This is further elaborated in [Table 1].
Table 1: Distribution of sample population among subcategories of the Child Behavior Checklist

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Neurological soft signs on physical and neurological examination for subtle signs – revised:

The results are presented in [Table 2]a, [Table 2]b, [Table 2]c, [Table 2]d, [Table 2]e.

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[NOTE: No further investigations apropos NSS were done by us as:

  1. The children who were our subjects were already certified SLD and satisfying the inclusion criteria that they had no known major medical, surgical, neurological, or psychiatric illness. They also did not display any acute neurological dysfunction at the interview
  2. They were managing their daily lives without any sense of significant impairment prior to our NSS evaluation, and our evaluation was only in keeping with our study parameters.

However, any significant findings from this study were explained to their parents, and they were given the option of further evaluations with developmental pediatrics and pediatric neurology services.

Analytical findings

  1. The association of CBCL with demographic and NSS parameters: The findings are presented in [Table 3]
  2. The association of NSS with demographic parameters:
Table 3: Significant associations (taken as P<0.05) of Child Behavior Check List with certain demographic parameters and neurological soft sign components (on Physical and Neurological Examination for Subtle Signs - Revised) using Chi-square test (denoted by χ2)*

Click here to view

The findings are presented in [Table 4].
Table 4: Significant relationships (taken as P<0.05) of neurological soft sign subcomponents on Physical and Neurological Examination for Subtle Signs - Revised with demographic data using Mann-Whitney test (denoted by U)

Click here to view

  Discussion Top

In observational findings, 18% of the children were left-handed in our sample and 2% were ambidextrous (almost double as compared to left-handers in the general population which is 10%). Associations between dyslexia and left-handedness/ambidexterity have been reported. Increased rate of learning disorders among left-handers is plausible because impairments of the left hemisphere that disturb language functions may also cause a shift of handedness to the right hemisphere.[7]

About 26% (i.e., more than one-fourth of sample population) children had a history of scholastic backwardness in primary family members. First degree-relation to an SLD person is known to increase the chance of SLD diagnosis in child up to 80 times more than children of non-SLD families.[8]

We saw a significant association between younger mothers (<20 years) and NSS suggesting that compromised fetal development and perinatal complications in younger mothers are likely to be more. However, a possible limitation to this finding would be that young motherhood itself could be tied to probable educational backwardness which could be due to SLD in the mother (e.g., poor in education and so married off early, which has not been assessed), and doubly make the child susceptible. This would have to be explored in more detail in the future.[9]

Ninety-five percent children had immediate cry after birth. However, they still had significant correlations with NSS, suggesting that other factors (genetic and intrauterine development) take more precedence over possibly minor natal complications (of which delayed cry is an indication), as also seen in previous studies.[10] 23% had delayed language milestones. There is a strong relationship between children's early language and phonological awareness/sensitivity and subsequent reading and spelling development, problem-solving as well as peer social interactions, as they entail good language/communication skills (compromised early linguistics portend poor future communication/social skills development).[9],[10],[11]

Our findings indicate that mothers were more involved in discipline, and the most common mode was verbal. Despite this, most children had a good relationship with mother but poor relationship with peers. The academic and learning problems of an SLD child result in poor self-concept, rejection or isolation from peers, or other obstacles to the development of social skills.[12] This perhaps leads them to feel even closer to the primary caregiver, usually the mother.

In academics, hardly any child in our study was in above-average group, as also seen in previous studies.[11],[12] 16.9% of the SLD students failed subjects. They are more likely to encounter frequent failure, perhaps leading to doubts about general intellectual abilities, in turn causing reduced effort, poorer academic outcomes, and psychopathology.[1] As 94% of parents perceived SLD as a problem, this may also be indicative of parental worries spilling over onto their children.

Coming to psychopathology, the detection of “clinical” range of symptoms on CBCL was compelling as psychiatric comorbidities were clinically excluded. Objective and clinical evaluations do not oftentimes exactly correspond but to surmise, such objective evaluations, i.e., scales do alert us to the possibility of subclinical signs/symptoms beginning to come to the fore; so perhaps, the clinical range of CBCL findings were budding symptoms which would with progressing time, as they become more prominent, be felt, seen and reported by the children/their parents. In addition, low mental health awareness or being preoccupied by SLD and its ramifications could also account for lack of reporting during the clinical evaluation.

On CBCL, 36.25% had “total,” i.e., significant behavioral problems, which falls in the percentage range of 30%–70%, incidence of behavioral problems in SLD children, as per previous studies.[8],[12] 41.875% of them had “internalizing” problem, significantly more than children with externalizing problem, as also in keeping with previous studies.[12],[13] More internalization is perhaps as children tend to get frustrated due to poor academic performance, failures and absorb criticism from parents/teachers, resulting in poorer self-image and increasing tendency for internalizing problems.

Somatic complaints were observed in nearly one-fifth of the sample population. Such complaints such as headaches, stomach-aches, and pain in writing hand are common in SLD children in their response to the stress of academic work, as also seen in previous research.[12],[13]

Due to low self-esteem, SLD children are afraid to turn their anger toward their environment and instead turn it inwards, becoming withdrawn/depressed. Young children tend to exhibit nonverbal cues and express their emotional struggles more by their behavior than by talking (which parents/teachers can observe). 14.4% of children were anxious-depressed in our sample. SLD children are generally more anxious than their nonlearning-disabled peers, as also seen in the previous research, with the anxiety manifesting itself as worry about studies, getting scolded for poor performance, avoidant tendencies, and concentration difficulties.[1],[12],[13]

Thirty percent of children in our sample had a higher score on “externalizing” category, which falls in the range of 12%–40% of SLD children displaying externalization, as also previously found.[1],[12],[13] Aggression was most common followed by rule-breaking behavior. Some SLD children have been described by parents as being more aggressive and more likely to engage in violence than peers, perhaps due to higher frustration levels and desire to defend themselves and establish their identities, as postulated from previous findings.[14]

In “other” category, 20% SLD children had a significant score on attention problem, which falls in the range of reported findings of 10%–60% SLD children having inattention.[10] Eighteen percent had significant score on social problem scale, reflecting previous findings stating SLD children with comorbidities such as hyperactivity, depressive, or other symptoms having substantial social skills difficulties.[1],[11],[13],[14]

In NSS outcomes, the discrepancy was found between reported handedness from parents' information and lateral preference pattern from PANESS. According to parents, 80% were right-handed, 18.1% left-handed, and 1.9% showed mixed handedness. However, on PANESS-R when lateral preference pattern was evaluated, out of the reported right-handed – 71.30% were truly right-handed, out of the reported left-handed – 8.80% were truly left-handed and rest 20% had mixed preference pattern. Therefore, 10.875% of the right-handed and 51.38% of the left-handed children (more than half of the reported left-handed children in our study) actually had mixed preference pattern. Previous studies show that left-handed children are less likely than their right-handed counterparts to choose their preferred hand, whether because social/academic retraining or personal preference, perhaps giving rise to such a finding in this study.[5] Ten percent of the general child population showing either left- or mixed-hand preference have delayed manifestation of handedness, suggesting delayed neurodevelopment in these individuals as compared to the right-handed (as corroborated by previous findings).[5],[11] Again, these individuals, due to delayed/compromised neurodevelopment, would be at more risk of developing SLD than those with timely neurodevelopmental milestones.

More than 50% of our sample had significant scores on most subcomponents of untimed and timed motor movements, involuntary movements and speed of movement subcomponents of PANESS-R, suggesting atypical neurodevelopment. These findings improve with age, i.e., the abnormalities become less with increasing age, as seen in our findings and also previous studies.[5],[11]

Mostly, 40%–70% of our study population had overflowed with gait, timed repetitive movements, in excess for age and total. Although repetitive speed of movement was the most common finding, overflow associated with it was the least. It may imply that the speed of movement improves much later than overflows. The persistence of overflow into late childhood/adolescence and other developmental disabilities suggests a neurodevelopmental lag in systems supporting the inhibition of overflow, as per preceding research.[5],[10],[11]

We found more asymmetry in the left-handed individuals. Our findings are similar to previous studies showing a higher score in dysrhythmia and speed of movement, perhaps suggesting left-handed individuals are more prone to atypical/delayed neurodevelopment.[10]

In finding statistical relationship between psychopathology on CBCL in SLD children and sociodemographic factors, we found that psychopathology is independent of age. This may be because, as previously researched, we have a competitive academic system in which there may be stress throughout.[13]

Punishment may have the disadvantage of the promotion of escape response producing emotional withdrawal. Similarly, it can cause observational learning of the undesirable behavior of punisher. Our findings showed children who experienced disciplining by father, and more physical discipline, had a higher score on externalizing category, as also seen in the previous research.[14] We found, however, children who had poor relationship with mother (irrespective of receiving physical discipline) had significant scores on externalizing and total category of CBCL, as also seen in preceding analyses.[15] Good interpersonal relationship with mother related to no demonstration of externalizing features, as perhaps, it balanced out negative feelings associated with discipline. Interpersonal relationship with father did not affect psychopathology in children. This may be as commonly fathers are less involved in childcare.

Those who had poor sibling and peer relationships also scored more on externalizing problems, which may actually be that they were driving away their peers or siblings due to poor behavior. Children who had either one or no close friend had a higher score on internalizing category, which may be indicative of loneliness and consequent personal distress. These findings are similar to those in previous studies.[1],[11],[12],[13],[15]

Those children who had a history of failure or repetition of grade had significant score on internalizing category. SLD children, most of who are doing relatively poorly in school, develop a sense of cognitive incompetence and helplessness leading to internalization.

Parents of children with externalizing problems reported learning disability as less of a problem, probably as they were more occupied by their children's behavioral problems, as also found in earlier research.[12],[13],[14]

Psychopathology on CBCL, when analyzed with NSS, showed a statistically significant association depicting that those who had significant score on overflow with patterned time movements also had significant total behavioral problem. It agrees with the “minimal brain dysfunction” hypothesis that children with more minimal neurological dysfunction clusters were found to have more behavior problems, perhaps tying behavioral disturbances as a manifestation of soft neurological dysfunction (as also reported in former studies).[16]

NSS, when correlated with sociodemographic factors, showed that gait and balance total error score, repetitive and patterned speed of movement score, and all overflows were significantly more in 7–11 years of age group. As previously found, test errors for gait and balance stations are more below 8 years. In addition, overflow usually decreases the most between 6 and 8 years, perhaps, as seen in previous studies, due to more rapid myelination of corpus callosum as a child grows older.[2],[11],[17] Both these findings thus suggest minor lag in CNS and consequently neuromuscular maturation in our study subjects.

Repetitive speed of movement score was significantly more in boys than girls. Overflow (with gait and total) was found significantly less in girls, as they tend to display fewer and less pronounced overflow movements throughout childhood and mature faster than boys. This has also been seen in previous research.[11],[16]

Repetitive speed of movement score (total, right) and patterned speed of movement score (total, left, and right) were significantly more in children of mothers of age below 20 years and 30–40 years at the time of delivery, as compared to 20–30 years of age group. Immediate or delayed cry did not make a difference, as both groups had a significant score on involuntary movement and overflow with gait, perhaps signifying age of mother at conception is a bigger factor in influencing the child's neurodevelopment than minor perinatal complications, as also corroborated by past findings.[2],[9],[11]

To summarize, 160 children with SLD were assessed for psychopathology, self-esteem, and NSS, and findings were statistically analyzed.

We found that 36.25% had psychopathology, with more having “internalizing problem,” of which, somatic complaints were the highest. Of the “externalizing problem” category, aggressive behavior was the highest. In the “other” category, attention problems were the highest. Total, internalizing and externalizing psychopathology was associated with poor interpersonal relations as well as being subjected to more physical discipline; in addition, the internalization problem was impacted more by academic failure and lack of friends. In addition, total psychopathology showed significant association with overflow subcomponent of NSS.

In testing for NSS, the most common was repetitive speed of movement, followed by involuntary movements. The total overflow was most frequent in the overflow category. More NSS were found in boys and in younger age groups (7–11 years). In addition, the speed of movement abnormalities was found more commonly in children of mothers who were <20 or above 30 years at the time of delivery.

In addition, there was high incidence of mixed handedness even in the right-handed. Most NSS were found more commonly in children with left and mixed preference pattern, though NSS on the right and left side were equally present in our study sample (with the exception of motor movement abnormalities, which were found more on the left). This suggests delayed neurological maturation in high percentage of SLD children.

  Conclusions Top

SLD is not only an invisible disability by itself, but in addition, associated NSS in several of them indicates possible dysfunctions of neurobiological nature which may interfere with skills necessary to navigate academics. Children with NSS also were found to have higher occurrence of psychopathology, i.e., they were more prone to both emotional and behavioral disorders.

Along with the detection and timely intervention, remedial education is found to have an added benefit of increasing self-worth and reducing emotional distress about academic performance and otherwise, albeit perhaps indirectly. Psychotherapy, behavioral therapy, and occasional psychopharmacological interventions are routinely done for SLD children detected with behavioral and emotional issues.

On the basis of our findings, along with regular screening of SLD children for budding psychopathology, we would recommend screening them routinely for NSS by sending for more detailed neurodevelopmental evaluation by liaising with pediatric neurology. It might help in identifying possible additional difficulties with sensory integration, fine motor coordination and motor sequencing, which originally were thought to be due to SLD only. In such children, along with remedial education for SLD, possible additional treatment in the form of occupational therapy for certain subparts of NSS may help in resolving such symptoms more effectively. We also recommend the objective assessment of psychopathology along with the existing clinical evaluation can be routinely added during SLD screening procedure to demarcate children more at risk of emotional/behavioral difficulties, and if detected, they can be managed accordingly with additional psychiatric evaluation and counseling, psychopharmacology as required and regular follow-ups. The possible limitations of this study were the lack of a control group and lack of PANESS normative data for Indian children.

Overall, this is a quantitative investigation in attempt to alert clinicians dealing with SLD about the possibility of associated problems of soft neurological dysfunctions along with behavioral and emotional issues in quite a few of their patients, so they may be vigilant and intervene early, thus helping SLD children toward a better quality of life. Further studies warranted are cross-sectional demographic studies to determine incidence and prevalence of comorbid SLD and NSS as well as screening non-SLD pediatric population for NSS to assess whether these findings can really be extrapolated; and longitudinal (along with interventional) undertakings for both SLD and NSS symptom amelioration with assessment for treatment effectiveness. Such findings would help delineate a more inclusive and comprehensive outlook in terms of both diagnosis and management.

Ethical statement

This study was approved by Institutional Ethics Committee with reference number PG/EC/107/2007with ECARP letter dated 27th July 2020.

Declaration of Patient Consent

Patient consent statement was taken from each patient as perinstitutional ethics committee approval along with consenttaken for participation in the study and publication of thescientific results / clinical information /image withoutrevealing their identity, name or initials. The patient is awarethat though confidentiality would be maintained anonymitycannot be guaranteed.

Financial support and sponsorship


Conflicts of interest

There are no conflicts of interest.

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  [Table 1], [Table 2], [Table 3], [Table 4]


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