children

Article
Children at Risk of Specific Learning Disorder: A Study on
Prevalence and Risk Factors
Leyla Bozatlı 1, * , Hasan Cem Aykutlu 1 , Açelya Sivrikaya Giray 2 , Tuğçe Ataş 3 , Çisem Özkan 4 ,
Burcu Güneydaş Yıldırım 5 and Işık Görker 1

1 Department of Child and Adolescent Psychiatry, Trakya University, Edirne 22000, Turkey;
[email protected] (H.C.A.); [email protected] (I.G.)
2 Department of Disability Studies, Faculty of Education, Trakya University, Edirne 22000, Turkey;
[email protected]
3 Artvin State Hospital, Artvin 08000, Turkey; [email protected]
4 İnegöl State Hospital, Bursa 16000, Turkey; [email protected]
5 Kırklareli Training and Research Hospital, Kırklareli 39000, Turkey; [email protected]
* Correspondence: [email protected]

Abstract: Background: Specific learning disorder (SLD) is a neurodevelopmental condition charac-

terised by significant academic difficulties despite normal intelligence and adequate education. The
difficulties with reading, writing, and arithmetic may manifest independently or concurrently at
different ages. Early symptoms may appear in preschool, including delays in social skills, motor
skills, and language development. This study aimed to assess the prevalence of preschool children at
risk for SLD and related psychiatric disorders. Method: Data were collected from 515 preschool chil-
dren in Edirne City, Turkey, using a screening scale for early symptoms of SLD. Socio-demographic
information was obtained, and children at risk were invited for a psychiatric evaluation. Results: The
mean age of the participants was 72.5 ± 5.6 months. It was determined that 5.7% of the preschool
children who participated in the questionnaire were at risk of SLD according to the screening scale
scores. Factors such as a father’s low education, the mother smoking during pregnancy, a longer
stay in the neonatal intensive care unit, longer screen time, and consanguinity between parents were
associated with an increased risk of SLD. Conclusion: This study emphasises the importance of early
Citation: Bozatlı, L.; Aykutlu, H.C.;
identification and intervention for SLD and the need to consider associated psychiatric comorbidities.
Sivrikaya Giray, A.; Ataş, T.; Özkan,
Identifying the risk factors in preschool children may facilitate timely intervention and prevent
Ç.; Güneydaş Yıldırım, B.; Görker, I.
academic and social difficulties in later years.
Children at Risk of Specific Learning
Disorder: A Study on Prevalence and
Keywords: early signs; specific learning disorder; dyslexia; preschooler
Risk Factors. Children 2024, 11, 759.
https://doi.org/10.3390/
children11070759

Academic Editor: Annio Posar 1. Introduction

Received: 24 May 2024 Specific learning disorder (SLD) is a neurodevelopmental disorder in which academic
Revised: 15 June 2024 skills are significantly below expected levels despite age, intelligence level, and appropriate
Accepted: 18 June 2024 education, and its aetiology involves the interaction of genetic, epigenetic, and environmen-
Published: 22 June 2024 tal factors. SLD is a condition that impairs one or more aspects of academic functioning,
including reading (dyslexia), writing (dysgraphia), and arithmetic (dyscalculia). These
types can occur separately or in combination. The incidence and prevalence of SLD vary
widely between studies, depending on the sample size, the method, the screening and
Copyright: © 2024 by the authors.
diagnostic tools used, and the Diagnostic and Statistical Manual of Mental Disorders (DSM-
Licensee MDPI, Basel, Switzerland.
IV/DSM-5) diagnostic criteria used [1]. In DSM-5, it has been reported that the prevalence
This article is an open access article
distributed under the terms and
of SLD in school-aged children from different languages and cultures is between 5–15%,
conditions of the Creative Commons
and the rates of reading disorder and dyscalculia are 4–9% and 3–7%, respectively [2].
Attribution (CC BY) license (https:// In a meta-analysis of studies conducted in India, the prevalence of SLD was reported to
creativecommons.org/licenses/by/ be 8% [3]. A study conducted in the United States of America (USA) reported a lifetime
4.0/). prevalence of learning disabilities in children of 9.7% [4]. In another study conducted in

Children 2024, 11, 759. https://doi.org/10.3390/children11070759 https://www.mdpi.com/journal/children

Children 2024, 11, 759 2 of 14

Brazil, the prevalence was 7.6% [5]. The number of prevalence studies using diagnostic
criteria or scales for SLD is small. However, it is accepted that SLD is relatively common
and under-recognised [1].
Although the characteristics of SLD may begin to appear in the preschool years or even
at a younger age, the diagnostic process for SLD usually begins with the child’s difficulties
with reading comprehension or learning, difficulties with writing or written expression,
difficulties with number perception/calculation, and when, as a result of these difficulties,
the child’s academic performance is below what would be expected for his or her age. In
addition to academic difficulties, these children also have difficulties in other areas during
the preschool years. Research has demonstrated that early signs of SLD encompass delays
in social skill development, challenges in adhering to rules, and difficulties with individual
and group work [6]. Additionally, SLD may manifest as motor skill delay, difficulty with
ball/balance games requiring hand-eye coordination, limited comprehension of speech,
and delays in receptive and expressive language development [7].
In recent years, there has been a growing emphasis among researchers on the early
detection of SLD during preschool years. They have focused on recognising the initial
symptoms and implementing early intervention strategies [7–9]. Studies highlight that
if children at risk of learning disabilities are identified during preschool and provided
with suitable intervention programs, the likelihood of receiving an SLD diagnosis during
their school years is significantly reduced [10–12]. The benefits of early intervention in
SLD extend beyond the academic realm. Research suggests that an early diagnosis of
SLD in children and interventions employed to address the issues related to the learning,
socialisation, and emotional development of these children can help to ameliorate the SLD
condition and its negative consequences for the child [13].
Although it is possible to identify and intervene in the early stages of SLD, studies
have mostly examined the risk factors, and there is not enough research on the prevalence of
the characteristics of SLD in the preschool years. Therefore, our objective was to assess the
prevalence of preschool children who are at risk of SLD and related psychiatric disorders.

2. Materials and Methods

A two-step study was conducted to identify preschool children at risk of SLD. In the
initial phase of the study, we conducted a screening process to identify early symptoms of
SLD in preschoolers during the spring semester of the 2021–2022 academic year. A study
investigating the prevalence of SLD in the same province found it to be 13.6% [14]. As our
research will be conducted in the same city centre, the data from this study were used, and
the target sample size was set at 610 people with a 95% confidence level and a margin of
error of d = 0.027. To account for stratification by sex, the target number was increased to
671. Following the approval from the Ethics Committee of the Medical Faculty of Trakya
University (protocol number 2022/43) and the acquisition of the necessary permissions
from the Provincial Directorate of National Education, a stratified random sampling method
was employed to select participants from the student class lists of 27 preschools in the
province. During this educational period, the city of Edirne had 31 schools with preschool
classes, with a total student enrollment of 2022. However, our study was conducted with
27 schools, excluding 3 schools located outside Edirne’s city centre and 1 “special education”
school. Thus, the study population comprised students enrolled in these 27 schools. Prior to
the commencement of this study, informed written consent was obtained from the parents
of the identified students. Children with a known psychiatric disorder, such as autism
or cognitive developmental delay, or children whose parents did not provide consent
were excluded from the study. The families who consented to participate completed a
socio-demographic questionnaire designed by the researchers and a standardised screening
tool for early symptoms of SLD.
Students who scored above the established cutoff for risk were invited to undergo a
comprehensive psychiatric evaluation at the Trakya University Faculty of Medicine Child
Psychiatry Clinic between eight and twelve months later in the subsequent academic year,
Children 2024, 11, 759 3 of 14

following the completion of at least six months of the first grade. In addition to assessing
SLD, the comprehensive psychiatric evaluation also assessed other psychiatric diagnoses
that may be comorbid with SLD, using the Kiddie Schedule for Affective Disorders and
Schizophrenia, Current and Lifetime Version [15,16].

2.1. Assessment Tools

We used the Learning Disability Early Symptoms Screening Scale [17] to evaluate the
early symptoms of specific learning disabilities in preschool children aged 4–6 years. The
scale has four subscales with 52 items in total: language development and communication
(14 items), cognitive skills (19 items), psychomotor skills (13 items), and social–emotional
skills (7 items). The items measure various skills and abilities that may be related to learning
disabilities, such as language, memory, attention, motor, and social skills. The items are
rated on a 5-point Likert scale, ranging from 1 (strongly disagree) to 5 (strongly agree), with
higher scores indicating a higher risk of learning disability. A few examples of some of
the questions in the scale can be found in the Supplementary Materials. The scale has a
minimum score of 52 and a maximum score of 260. The raw scores of each subscale and the
total scale were converted into Z and T scores based on the standardised group mean and
standard deviation. The standardised group arithmetic means and standard deviations
were obtained for each subtest and the total scale score. The score ranges were calculated
for each subtest according to the standard score ranges resulting from the group arithmetic
mean and standard deviation obtained, and 4 risk groups were defined according to the
score ranges of very low, mild, moderate, and high risk. This provided a detailed screening
of the participants for risk categorisation.
To obtain a representative sample of children at risk for SLD, we operationally defined
the ‘at-risk’ group as children who scored at a ‘moderate risk’ or ‘high risk’ level on the total
scale score or any of the four subscales. Conversely, we categorised the ‘low-risk group’ as
participants who obtained scores that were indicative of a ‘very low risk’ or ‘mild risk’.
Kiddie-Schedule for Affective Disorders and Schizophrenia—Present and Lifetime
Version is a semi-structured diagnostic interview tool that probes the current and past
stages of childhood and adolescent psychiatric disorders [15]. The Turkish version of
K-SADS-PL was reported to show good test–retest and interrater reliability [16]. In this
study, it was used to diagnose psychiatric disorders accompanying SLD.

2.2. Statistical Analysis

In this descriptive study, we computed the statistical measures, including the mean/
median, standard deviation/interquartile range, and 95% confidence interval. The preva-
lence value was also presented as a percentage. To draw comparisons between the quan-
titative data of children with and without a SLD risk, we employed either the Student’s
t-test or the Mann–Whitney U test, contingent on the data’s distribution characteristics.
The Chi-square test was utilised for the comparison of categorical data. Logistic regression
analysis was conducted to evaluate the potential risk factors influencing SLD. The inclusion
criteria of the variables in the binary logistic regression model were set among those that
were significant (p < 0.10) by univariate comparisons. A p-value of less than 0.05 was
considered statistically significant. All statistical analyses were performed using SPSS
version 20 for Windows (IBM SPSS Statistics for Windows, Version 20.0. Armonk, NY, USA:
IBM Corp.)

3. Results
Our primary objective was to conduct a survey involving 671 students. However,
due to incomplete responses on the measurement scales or a lack of willingness to partici-
pate, we were only able to analyse data from 490 students, as provided by their parents
(Figure 1). The mothers completed 89.9% of the forms. The mean age of the participants
was 72.5 ± 5.6 SD months, and 50.7% of the children were female (Table 1).
 3. Results
Our primary objective was to conduct a survey involving 671 students. However, due
to incomplete responses on the measurement scales or a lack of willingness to participate,
we were only able to analyse data from 490 students, as provided by their parents (Figure
Children 2024, 11, 759 1). The mothers completed 89.9% of the forms. The mean age of the participants was 72.54 of 14
± 5.6 SD months, and 50.7% of the children were female (Table 1).

Flowchart
Figure1.1.Flowchart
Figure ofof
thethe study
study sample.
sample.

Table 1. Descriptive information of the study sample.

Age Month 72.5 ± 5.6

Sex Boy 49.3% (n = 254)
Girl 50.7% (n = 261)
Parents who filled out the form Mother 88.9% (n = 458)
Father 11.1% (n = 57)
Siblings Yes 69.3% (n = 357)
No 30.7% (n = 158)
Number of siblings 1 (1–3)
First-born 53.2% (n = 274)
Second-born 41% (n = 211)
Third-born 5.2% (n = 27)
Fourth-born 0.6% (n = 3)
Children 2024, 11, 759 5 of 14

Table 1. Cont.

Marital Status Together 93.2% (n = 480)

Divorced 3.5% (n = 18)
Separated 1% (n = 5)
Death 0.4% (n = 2)
Missing value 1.9% (n = 10)
Number of people living in the home 4 (2–7)
Mother’s age 35.6 ± 5.1
Mother’s job Working 40% (n = 298)
Not working 57.9% (n = 298)
Missing value 2.1% (n = 11)
Mother’s education Illiterate 0.4% (n = 2)
Literate 0.6% (n = 3)
Primary school 6% (n = 31)
Secondary school 12% (n = 62)
High school 36.7% (n = 189)
University 42.5% (n = 219)
Missing value 1.7% (n = 9)
Father’s age 38.77 ± 5.41
Father’s job Working 94.4% (n = 486)
Not working 3.5% (n = 18)
Missing value 2.1% (n = 11)
Father’s education Illiterate 0.2% (n = 1)
Primary school 5.4% (n = 28)
Secondary school 15.1% (n = 78)
High school 38.4% (n = 198)
University 38.7% (n = 199)
Missing value 2.1% (n = 11)
Family income Less than 5000 TL 21.7 (n = 112)
5–10,000 TL 41.9% (n = 216)
10–15,000 TL 21.6% (n = 111)
More than 15,000 TL 10.5% (n = 54)
Missing value 4.3% (n = 22)
n (%), mean ± SD, median (min–max).

A total of 27.6% (n = 135) of the study sample was identified as at risk for SLD
(Figure 2). The SLD risk group had statistically significantly higher scores in four subscales
of the Early Symptoms of Learning Disabilities Screening Scale (language development
and communication skills, cognitive skills, psychomotor skills, psychosocial skills, and
social–emotional skills) compared to the low-risk group (Table 2).

Table 2. Early symptoms of learning disabilities screening scale scores between the risk and low-
risk groups.

Low-Risk Group Risk Group

Median (Min–Max) Median (Min–Max) pa
(n = 355) (n = 135)
Language Development and
3 (1–9) 6 (1–20) <0.001
Communication Skills
Cognitive Skills 6 (1–9) 10 (1–19) <0.001
Psychomotor Skills 3 (1–9) 6 (1–20) <0.001
Social–Emotional Skills 3 (1–19) 7 (1–19) <0.001
Total Score 87 (4–131) 120 (20–247) <0.001
a: Mann–Whitney U test.
 Children 2024, 11, x FOR PEER REVIEW 6 of 14

Children 2024, 11, 759 6 of 14

communication skills, cognitive skills, psychomotor skills, psychosocial skills, and social–
emotional skills) compared to the low-risk group (Table 2).

Figure 2. The specific learning disorder risk groups.

Figure 2. The specific learning disorder risk groups.
Table 2. Early symptoms of learning disabilities screening scale scores between the risk and low-
We
risk compared the socio-demographic data between the groups and found that fathers
groups.
of children in the high-risk group had a lower level of education (p = 0.017), mothers
Low-Risk
smoked more during pregnancy (p =Group Risk Group
0.004), and children stayed longer in the neonatal
intensive care unit (p = 0.039), had more daily screen time (p = 0.009), pand had more
Median (Min–Max) Median (Min–Max) a

(n = 355) (n = 135)
consanguineous parents (p = 0.023) (Table 3).
Language Development and Communication Skills 3 (1–9) 6 (1–20) <0.001
Cognitive Skills 6 (1–9) 10 (1–19) <0.001
Table 3. Comparison of the specific learning disorder risk groups for variables.
Psychomotor Skills 3 (1–9) 6 (1–20) <0.001
Social–Emotional Skills 3 (1–19)
Low-Risk Group (n = 355) 7 (1–19)
Risk Group (n = 135) <0.001 p
Total Score 87 (4–131) 120 (20–247) <0.001
Age Month
a: Mann–Whitney U test. 72 (IQR = 6) 71 (IQR = 7) 0.510 MU
Boy 48.2% (n = 171) 52.6% (n = 71) CS
Sex We compared the socio-demographic
Girl 51.8% (n = 184)data between the groups
47.4% 64) found that 0.382
(n = and fathers
of children in the high-risk group had a lower level of education (p = 0.017), mothers
Yes 68.5% (n = 243) 69.6% (n = 94)
Siblings 0.801 CS
smoked more during pregnancy (p = 0.004), and children stayed longer in the neonatal
No 31.5% (n = 112) 30.4% (n = 41)
Number of siblings 1 (IQR = 0) 1 (IQR = 0) 0.728 MU
Together 94% (n = 330) 97.7% (n = 130)
Divorced 4.3% (n = 15) 2.3% (n = 3)
Marital Status
Separated 1.4% (n = 5) 0% 0.325 CS
Parental loss 0.3% (n = 1) 0%
Number of people living in
4 (IQR = 1) 4 (IQR = 1) 0.685 MU
the home
Children 2024, 11, 759 7 of 14

Table 3. Cont.

Low-Risk Group (n = 355) Risk Group (n = 135) p

Mother’s age 35 (IQR = 7) 35 (IQR = 7) 0.370 MU
Working 42.9% (n = 150) 38.6% (n = 51)
Mother’s job 0.402 CS
Not working 57.1% (n = 200) 61.4% (n = 81)
Low 6.3% (n = 22) 9.8% (n = 13)
Mother’s education Medium 47.4% (n = 167) 51.1% (n = 68) 0.216 CS
High 46.3% (n = 163) 39.1% (n = 52)
Father’s age 38 (IQR = 7) 38 (IQR = 7) 0.708 MU
Working 96% (n = 336) 97.7% (n = 129)
Father’s job 0.580 f
Not working 4% (n = 14) 2.3% (n = 3)
Low 3.4% (n = 12) 9.8% (n = 13)
Father’s education Medium 54.9% (n = 192) 53.4% (n = 71) 0.017 CS
High 41.7% (n = 146) 36.8% (n = 49)
Low 19.6% (n = 67) 29% (n = 38)
Family income Medium 69.6% (n = 238) 61.1% (n = 80) 0.087 CS
High 10.8% (n = 37) 9.9% (n = 13)
yes 81.4% (n = 289) 79.3% (n = 107)
Planned pregnancy 0.589 CS
no 18.6% (n = 66) 20.7% (n = 28)
yes 7.4% (n = 26) 5.9% (n = 8)
Assisted reproductive techniques 0.566 CS
no 92.6% (n = 325) 94.1% (n = 127)
yes 15.3% (n = 54) 16.4% (n = 22)
Threat of miscarriage 0.761 CS
no 84.7% (n = 299) 83.6% (n = 112)
Medical illness in mother yes 8.2% (n = 29) 9.6% (n = 13)
during pregnancy no 91.8% (n = 324) 90.4% (n = 122) 0.618 CS

yes 28% (n = 98) 26.1% (n = 35)

Medication use in pregnancy 0.678 CS
no 72% (n = 252) 73.9% (n = 99)
yes 29.6% (n = 105) 37.8% (n = 51)
Smoking before pregnancy 0.082 CS
no 70.4% (n = 250) 62.2% (n = 84)
yes 5.6% (n = 20) 13.3% (n = 18)
Smoking during pregnancy 0.004 CS
no 94.4% (n = 335) 86.7% (n = 117)
yes 0% 0.8% (n = 1)
Alcohol use during pregnancy 0.274 f
no 100% (n = 352) 99.2% (n = 132)
yes 86.7% (n = 301) 90.8% (n = 119)
Supplementary use in pregnancy 0.221 CS
no 13.3% (n = 46) 9.2% (n = 12)
Gestation week 38 (IQR = 1) 38 (IQR = 1.3) 0.627 MU
Birth length cm 50 (IQR = 4) 50 (IQR = 3) 0.496 MU
Birth weight gr 3300 (IQR = 680) 3350 (IQR = 742.5) 0.620 MU
Postpartum intensive care yes 9.1% (n = 32) 15.6% (n = 21)
unit hospitalisation no 90.9% (n = 321) 84.4% (n = 114) 0.039 CS

Breastfeeding month 18 (IQR = 18) 18 (IQR = 18) 0.858 MU

Walking milestone month 12 (IQR = 2) 12 (IQR = 2.3) 0.058 MU
Sentence formation milestone month 18 (IQR = 11.8) 18 (IQR = 12) 0.860 MU
yes 2% (n = 7) 3% (n = 4)
History of epilepsy 0.506 CS
no 98% (n = 346) 97% (n = 131)
yes 10.2% (n = 36) 11.9% (n = 16)
History of surgery 0.585 CS
no 89.8% (n = 316) 88.1% (n = 118)
yes 0.3% (n = 1) 1.5% (n = 2)
History of head trauma 0.187 f
no 99.7% (n = 351) 98.5% (n = 133)
Children 2024, 11, 759 8 of 14

Table 3. Cont.

Low-Risk Group (n = 355) Risk Group (n = 135) p

right 84.7% (n = 300) 88.1% (n = 119)
Hand preference left 10.5% (n = 37) 8.9% (n = 12) 0.565 CS
both 4.8% (n = 17) 3% (n = 4)
Screen time minute 180 (IQR = 120) 210 (IQR = 150) 0.009 MU
1st class with
98.3% (n = 343) 96.1% (n = 124)
peers
1st class later
0.9% (n = 3) 1.6% (n = 2)
Mother’s reading milestone than peers 0.555 CS
2nd class 0.6% (n = 2) 1.6% (n = 2)
3rd class or
0.3% (n = 1) 0.8% (n = 1)
later
1st class with
98% (n = 342) 97.7% (n = 128)
peers
1st class later
0.9% (n = 3) 1.5% (n = 2)
Father’s reading milestone than peers 0.750 CS
2nd class 0.6% (n = 2) 0.8% (n = 1)
3rd class or
0.6% (n = 2) 0%
later
Yes 1.4% (n = 5) 5.3% (n = 7)
Kinship 0.023 f
No 98.6% (n = 346) 94.7% (n = 126)
1st 20% (n = 1) 16.7% (n = 1)
Degree of kinship 2nd 40% (n = 2) 33.3% (n = 2) 0.946 CS
3rd 40% (n = 2) 50% (n = 3)
MU Mann–Whitney U test, CS Pearson Chi-square, f Fischer’s exact test, p < 0.05.

Multiple regression analysis showed that consanguinity between parents (p = 0.014,

Exp(B) = 6) and more screen time (p = 0.033, Exp(B) = 1.002) also predicted the risk group.
The logistic regression model was statistically significant (X2(10) = 20.058 and p = 0.029)
and well-fitted to the data, as indicated by the correlations of estimates and the Hosmer–
Lemeshow goodness-of-fit test (X2(8) = 3.535, p = 0.896). The model explained 69% of the
variance in SLD, as measured by Nagelkerke R2 (Table 4).
In the study’s second phase, children at risk for SLD were invited to attend the child
psychiatry outpatient clinic for clinical assessment. Nevertheless, only 19.3% (n = 26) of
the children and their families visited the clinic, allowing for their assessment. Psychiatric
disorders were diagnosed in 92.3% (n = 24) of the assessed children. Among the cases with
a psychiatric diagnosis, there were also cases with psychiatric comorbidities. The specific
psychiatric diagnoses were as follows: 41.7% had SLD (n = 10), 83.3% had ADHD (n = 20),
20.8% had anxiety disorder (n = 5), 8.3% had speech disorder (n = 2), 8.3% had eating
disorder (n = 2), 4.2% had OCD (n = 1), and 4.2% had an intellectual disability (n = 1).
While all children identified in the risk group were invited for psychiatric evaluation,
only 19.3% of them were examined. To understand the reasons behind the non-attendance
of certain families, we compared the characteristics of those who attended the psychiatric
evaluation and those who did not. The comparison was based on the following characteris-
tics: gender (p = 0.768), presence of siblings (p = 0.169), marital status (p = 0.482), mother’s
employment status (p = 0.984), mother’s health problem (p = 1.000), maternal education
(p = 0.365), paternal employment status (p = 0.485), paternal health problem (p = 0.737),
paternal education (p = 0.054), kinship (p = 0.345), family income (p = 0.660), and social
security status (p = 1.000). No statistically significant differences were found between the
two groups based on these characteristics.
Children 2024, 11, 759 9 of 14

Table 4. Regression analysis for predicting SLD risk.

95% I. for
B S.E. Wald df Sig. Exp(B) Exp(B)
Lower Lower
Low 3.015 2 0.222
Father’s education Medium −0.887 0.512 3.001 1 0.083 0.412 0.151 1.124
High −0.793 0.536 2188 1 0.139 0.452 0.158 1.294
Low 0.951 2 0.622
Family income Medium −0.230 0.294 0.614 1 0.433 0.794 0.447 1.413
High 0.033 0.449 0.005 1 0.941 1.034 0.429 2.493
Smoking before pregnancy (yes) 0.114 0.272 0.176 1 0.674 1.121 0.658 1.909
Smoking during pregnancy (yes) 0.191 0.456 0.176 1 0.675 1.211 0.496 2.958
Postpartum intensive care unit
0.375 0.343 1.192 1 0.275 1.454 0.742 2.850
hospitalistion (yes)
Walking milestone 0.004 0.042 0.008 1 0.929 1.004 0.925 1.090
Screentime 0.002 0.001 4.527 1 0.033 1.002 1.000 1.004
Kinship (yes) 1.792 0.729 6.040 1 0.014 6.000 1.437 25.043
Constant −0.683 0.783 0.760 1 0.383 0.505

4. Discussion
We aimed to estimate the prevalence of preschool children at risk of SLD and to follow
them up in primary school to see if they received a clinical diagnosis of SLD. Our sample’s
total scale score indicated that 5.7% of preschool children were at risk of SLD. When we
also examined the subscale scores, the prevalence of children at risk for SLD increased to
27.6%. To our knowledge, no other study has explored the prevalence of children at risk of
SLD in this population.
The prevalence of specific learning disorders (SLD) varies across studies from different
countries [1]. Epidemiological studies and government reports in 2004–2005 indicated that
the prevalence of learning disabilities in Greece was between 1.2% and 1.4%. In contrast, the
prevalence rate of SLD among children aged 3–17 years was 9.7% in the United States [4].
Moreover, the prevalence of SLD in primary school children was 7.7% in Pakistan [18] and
13.6% in Turkey [14]. According to the DSM, the prevalence of SLD in reading, writing, and
mathematics ranged from 5% to 15% among school-aged children in different languages
and cultures [2]. However, some studies have found a higher prevalence of SLD. For
example, in a study conducted in India, the prevalence of SLD was 30.77% [19], while
in a review article analysing studies conducted in India, this rate was between 2% and
33% [20]. Similarly, in a study in Turkey where symptoms of SLD were screened through
a questionnaire form, this rate was reported as 36.8% on teacher forms and 37.9% on
parent forms [21]. As a result of the studies and meta-analyses, the reported rates for
the prevalence of SLD spanned a very wide range. This wide range is explained by the
population and country in which the studies were conducted, the language used, the
presence and variety of screening tools in the country, the study method (screening tools,
clinical assessment), and whether the study was conducted according to the DSM-IV or
DSM-5 criteria before or after 2013 [1]. In our study, the prevalence rate of SLD symptoms
was close to the SLD rate reported in the DSM and the literature. Therefore, our SLD risk
ratio results (5.7% with the total scale scoring and 27.6% when considering the subscale
scores and medium risk group) are consistent with the wide range of SLD prevalence
reported in the literature.
When assessing for SLD risk in preschool children, it is important not to overlook other
psychiatric disorders that share common symptoms and causes with SLD. In this study,
we invited children at risk for specific learning disabilities to undergo a comprehensive
Children 2024, 11, 759 10 of 14

psychiatric assessment at our outpatient clinic after a one-year follow-up upon finishing
first grade. However, only 19.3% of the children completed the assessment, which was a
significantly lower rate than expected. To understand the reason for the low participation,
the characteristics of the families who attended the clinical assessment and those who
did not (child’s gender, siblings, marital status, parents’ education, employment status,
health, family income, social security, and kinship) were analysed, but no difference was
found. Although the reason for the low participation is unknown, it suggests that parents’
awareness of SLD may be low. Furthermore, parents may seek assessments for their
children who exhibit pronounced behavioural symptoms or developmental delays relative
to their age-matched peers.
The psychiatric assessment results showed that 92.3% of the children evaluated had a
psychiatric disorder such as attention deficit hyperactivity disorder (ADHD), SLD, anxiety
disorder, obsessive-compulsive disorder (OCD), intellectual disability, or an eating disorder.
Notably, SLD was diagnosed in 38.46% of these cases. Interestingly, ADHD was diagnosed
in 83.3% of the patients, indicating a strong correlation between ADHD and SLD. This
association is supported by previous studies, such as the research by Visser et al. (2020),
which found that 28% of 3014 children with SLD also had ADHD [22]. Moreover, studies
focusing on hyperactive children frequently report academic failure and learning difficul-
ties. Numerous epidemiological studies have also found associations between SLD and
hyperactivity, as well as between specific subtypes of ADHD and SLD and their respective
symptoms [23]. These findings emphasise the importance of early identification and inter-
vention for children who are at risk of SLD. They also suggest that SLD is a heterogeneous
disorder that can manifest in various ways and interact with other disorders. Further
research is necessary to investigate the causes, mechanisms, and outcomes of SLD and its
comorbidities during the preschool period.
The prevalence of smoking during pregnancy was higher among mothers of children
in the risk group for SLD (p = 0.004). Studies investigating the effects of maternal smoking
have reported an increased risk of preterm birth, low birth weight, ADHD, and learning
difficulties [24]. Research has shown that smoking during pregnancy is linked to ADHD in
the child [25,26]. Additionally, mothers who smoke more than 20 cigarettes per day during
pregnancy have an increased risk of their children developing intellectual disability [27].
Furthermore, smoking during pregnancy has long-term negative effects. According to Fer-
gusson et al. (1998), smoking during pregnancy is associated with an increase in psychiatric
symptoms in late adolescence. The study also reported that exposure to cigarette smoke
during pregnancy is associated with increased rates of psychiatric symptoms with increasing
doses. In conclusion, studies have shown that smoking during pregnancy is associated with
early and late psychiatric symptoms and diagnoses [28]. Our study found that the SLD risk
group was diagnosed with ADHD (83.3%), anxiety disorder (20.8%), an eating disorder
(8.3%), a speech disorder (8.3%), OCD (4.2%), and intellectual disability (4.2%) in addition
to SLD. This evidence further corroborates the existing body of research in this field.
Our study revealed that fathers of children at risk for SLD had lower educational
levels (p = 0.017). This finding aligns with a previous study conducted in the same region,
which associated lower paternal education with an increased risk of SLD in children [14]. In
the broader context, research on early childhood development often considers maternal or
parental education as a whole [29,30]. However, few studies have separately examined the
impact of the father’s educational level [31]. One such study, conducted across 44 low- and
middle-income countries, analysed the relationship between both maternal and paternal
education levels and children’s early development. The results indicated a correlation be-
tween the parents’ educational level and early childhood development. Specifically, higher
maternal and paternal education levels were linked to better early childhood development
outcomes. Furthermore, the parents’ educational levels were positively associated not
only with their own parenting practices but also with the other parents’ interactions with
the child. The study also found that the manner in which caregivers support the child’s
learning process influences the child’s development significantly [31].
Children 2024, 11, 759 11 of 14

Intensive care in the neonatal period can have long-term consequences for a baby’s
health. However, these situations are complex and depend on many factors. Babies may
need intensive care for a variety of reasons, including prematurity, complications during
labour, infections, or other health problems. On the other hand, intensive care can disrupt
the natural bonding process essential for children’s growth and development. In our study,
the rate of neonatal intensive care stay was higher in cases identified as being at risk of SLD
(p = 0.039). Similarly, many researchers have reported that children treated in the intensive
care unit have significant educational problems [32,33].
We found that children born from consanguineous marriages had a higher likelihood
of being in the SLD risk group (p = 0.023). When we applied multiple regression to the data,
consanguineous marriage was one of the two risk factors that remained significant for SLD
risk (p = 0.014, Exp(B) = 6). Consanguineous marriage is defined as a marriage between
close biological relatives (first and second cousins). The rate of consanguineous marriages
in different countries depends on various factors such as education level, religion, local
traditions, and socio-economic status [34]. Consanguineous marriages, especially between
first cousins, are associated with an increased incidence of several inherited diseases,
including intellectual disability and psychiatric disorders [35,36]. Studies have suggested
possible negative consequences of consanguineous marriage, such as reduced fertility and
an increased risk of infant mortality, congenital disease, and intellectual disability [37].
There is also considerable evidence that reading disability may be inherited as a family trait.
A study investigating reading disability in children born into consanguineous marriages
reported a significant association between consanguineous marriage and an increased risk
of reading disability, highlighting the effect of genetics. The study assessed the reading
skills of 770 students and compared the performance of two experimental groups with
reading difficulties: 22 students from first-cousin marriages and 21 children from unrelated
parents. The control group consisted of 21 children with typical reading skills. The results
showed that children of cousin parents were more likely to have reading difficulties than
children of parents from other families [38].
In the current technological era, screens have become an increasingly common aspect
of daily life. The impact of these devices (smartphones, tablets, computers, and televisions)
that make our lives easier on children’s development and education is of great interest to
researchers. Although the use of digital devices is spreading rapidly among very young
children, the effects of screen time on emotional and cognitive functions are still being
debated. A longitudinal study (4–8 years) assessing emotional regulation and academic
performance reported that children’s screen time was positively and significantly associ-
ated with mood dysregulation at age 4 and negatively associated with mathematics and
literacy performance at age 8 [39]. In a further study that focused on the preschool period,
researchers noted that a child’s first screen exposure to television may be formative because
of developmental differences between preschool and later childhood. The importance of
this period is explained by the fact that habit formation and overexposure in the early
period increase the likelihood of overexposure later in life and that screen use tends to
increase over time to include more entertainment as opposed to viewing for educational
purposes only [40]. Screen time has also been linked to attention span. A meta-analysis
of studies examining this relationship reported a negative association between increased
screen time and attention span [41]. On the other hand, time spent with parents is also
important. In a study that examined the time children spent with four digital media devices
(TV, computer, smartphone, and tablet computer) using a nationally representative sample
of more than 2300 parents of children aged 0–8 years, results from linear regression analy-
ses showed that parents’ own screen time was strongly related to their children’s screen
time. Further analysis shows that children’s screen time use is the result of an interaction
between child and parent factors and is strongly influenced by parental attitudes [42]. Due
to the role of parents in the development of their children’s physical activity and sedentary
behaviour, especially in the early years, the effect of parental influence on screen time
and physical activity in young children has been investigated. The results suggest that
Children 2024, 11, 759 12 of 14

parental encouragement and support can increase children’s physical activity and that
reducing parents’ own screen time can lead to a reduction in children’s screen time. In light
of these findings, it has been reported that improving parental self-efficacy or changing
parenting styles may be beneficial in increasing young children’s physical activity and
reducing screen time [43]. Although it is noted that screens can have a positive effect on
accessing information outside the daily routine, learning vocabulary/language, or general
cultural information, the key point here is that screen time and content should be under
parental control [40].
The significant increase in screen time among the group at risk for SLD (p = 0.009),
which remained significant after regression analysis (p = 0.033), coupled with a high rate of
psychiatric diagnosis (92.4%) among those assessed, underscores the need for comprehen-
sive studies on the effects of screen use. This is particularly relevant given the ubiquity of
digital media tools in various areas such as education, work, communication, and entertain-
ment. The recent surge in mental health issues among young people has been hypothesised
to be linked to increased screen-based technology usage. However, these hypotheses are
primarily based on cross-sectional studies. Therefore, more longitudinal studies examining
screen content and the motivations for screen use are warranted to elucidate the relation-
ship between screen time and mental health symptoms [44]. Concurrently, it is crucial to
conduct studies on rational digital use and disseminate the findings to society, given the
mobile and easily accessible nature of digital media tools.

5. Conclusions
Although the diagnostic process for SLD typically commences after primary school,
early symptoms can be observed during the preschool years. Our study found a high
prevalence of preschool children at risk for SLD, many of whom also have a wide range of
psychiatric comorbidities. However, parents are often oblivious to the symptoms. It has
been reported that there is a four-year gap between the time a mother first suspects SLD
symptoms and the child’s actual diagnosis [45]. This gap can be reduced by identifying
the risk factors and clinical signs of SLD in preschool children, as well as by increasing the
awareness and involvement of teachers in the referral process. Teachers can facilitate early
intervention by recognising the learning difficulties and preferences of each child and by
collaborating with child and adolescent psychiatrists to design individualised educational
programmes. Further research is necessary to enhance understanding of the risk of SLD
and its management.

Supplementary Materials: The following supporting information can be downloaded at: https://
www.mdpi.com/article/10.3390/children11070759/s1, The Learning Disability Early Symptoms
Screening Scale (LDESSS).
Author Contributions: Conceptualisation, L.B., H.C.A. and I.G.; methodology, L.B., H.C.A. and I.G.;
validation, L.B., H.C.A. and I.G.; formal analysis, L.B. and H.C.A.; investigation, resources, data
curation, L.B., H.C.A., A.S.G., T.A., Ç.Ö., B.G.Y. and I.G.; writing—original draft preparation, L.B.,
H.C.A., A.S.G., T.A., Ç.Ö., B.G.Y. and I.G; writing—review and editing, L.B., H.C.A. and I.G. All
authors have read and agreed to the published version of the manuscript.
Funding: This research received no external funding.
Institutional Review Board Statement: Approval for the study was granted by the Trakya University
Social Science Ethical Committee (number E-76244175-050.01.04-230032), ethics date: 12 May 2023.
Informed Consent Statement: Informed consent was obtained from all subjects involved in the study.
Data Availability Statement: The data presented in this study are available on request from the
corresponding author due to privacy restriction.
Acknowledgments: We would like to thank all participants who volunteered for this research.
Conflicts of Interest: The authors declare no conflicts of interest.
Children 2024, 11, 759 13 of 14

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