Dr. Karande's presentation at the Tata Learning Disability Forum (TLDF), 2013

1. Poor School Performance
Dr. Sunil Karande
Professor of Pediatrics &
In-Charge Learning Disability Clinic
Department of Pediatrics
Seth G.S. Medical College & K.E.M. Hospital
Parel, Mumbai.

2. Introduction
• ~20% of children in a classroom get poor marks - they are
“scholastically backward”
• “Symptom” reflecting a larger underlying problem in children
• Results in child having a low self-esteem
•
Significant stress to parents
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3. Causes of PSP
• Medical problems
• Low intelligence (Slow Learners and Mental Retardation)
• Specific learning disability (SpLD)
• Attention-deficit hyperactivity disorder (ADHD)
• Emotional problems
• Poor socio-cultural home environment
• Psychiatric disorders
• Environmental causes
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4. Medical Problems
• Preterm birth
• Low birth weight
• Malnutrition
• Worm infestation
• Hearing impairment (e.g. otitis media)
• Visual impairment (e.g. refractive error)
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5. Medical Problems
• Asthma • Hemophilia
• Allergic rhinitis • Diabetes Mellitus
• Epilepsy (& AEDs) • Hypothyroidism
• Cerebral Palsy • Sleep disordered
• Leukemia breathing (habitual
snoring)
• Thallasemia major
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6. Low Intelligence
• Intelligence (IQ score): most important prognostic variable
• Borderline intelligence or “slow learners” (IQ 71 to 84)
• Mental retardation (IQ ≤ 70) e.g. Down syndrome
• Risk factors: prematurity, meningitis, severe head injury
• Usually have history of delayed milestones
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7. SpLD
• heterogeneous group of disorders
• manifested by significant unexpected, specific and persistent
difficulties in acquisition and use of reading (dyslexia), writing
(dysgraphia) or mathematical (dyscalculia) abilities
• despite conventional instruction, normal intelligence, proper
motivation and adequate socio-cultural opportunity
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8. What happens in dyslexia?
• Deficits in phonologic awareness
• “Phoneme”: smallest discernible segment of speech
• "bat" consists of three phonemes:
/b/ /ae/ /t/ (buh, aah, tuh)
• Poor awareness that: words, both written and spoken, can be
broken down into smaller units of sound; and letters constituting
printed word represent sounds heard in spoken word
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9. • ~5-12% school children have dyslexia
• Red flags for dyslexia:
* history of language delay
* not attending to sounds of words
(trouble playing rhyming games with words, or confusing
words that sound alike)
* positive family history
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10. Symptoms of SpLD
• Children with SpLD fail to achieve school grades at a level
that is commensurate with their intelligence
• Repeated spelling mistakes, untidy or illegible handwriting
with poor sequencing, inability to perform simple
mathematical calculations correctly
• Life-long condition
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11. ADHD
• ADHD affects 8-12% of children
• Results in inattention, impulsivity and hyperactivity
• Some have predominant inattention, some have, impulsivity and
hyperactivity, some have both
• At risk for poor school performance
• 20-25% of children with ADHD have SpLD & vice versa
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12. Autism
• Impairment of reciprocal social interactions
• Impaired communication skills
• Restricted range of interests or repetitive behaviors
• Demonstrate distress and oppositionality when exposed to
requests to complete academic tasks
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13. Emotional Problems
• Chronic neglect
• Parents getting divorced
• Losing a sibling
• Chronic health impairments
• Sexual abuse
Resulting in low self-esteem & loss of motivation to study
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14. Poor socio-cultural environment
• Language barrier
• Malnutrition due to poverty
• Low education status of parents
• Parental attitudes which do not motivate them to study
• Unsatisfactory home environment (domestic violence, family
stressors, adverse life events)
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15. Psychiatric disorders
• Early signs of emerging or existing anxiety, depression or
psychosis
• Conduct disorder and oppositional defiant disorder
• Change in child’s personality
• Deteriorating school performance
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16. Environmental causes
• Noisy environment
• Unattractive schools
• Too much television viewing (lack of sleep)
• Exposure to lead
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17. Management of Poor School Performance
• Child may be having ≥1 reason
• Refer early for evaluation
• Information from parents, classroom teachers & school
counselor crucial
• Information should clearly describe child’s academic
difficulties, behavior & social functioning
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18. Multidisciplinary approach
• Pediatrician
• Ophthalmologist
• Otolaryngologist
• Counselor
• Clinical Psychologist
• Child Psychiatrist
• Special Educator
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19. Treatment of Medical Problems
• If any specific ‘medical’ reason identified, pediatrician should
treat it as effectively as possible
e.g. optimum control of asthma or epilepsy
• Correction of hearing and/or visual impairment
• Children irrespective of their physical, sensory, or
neurobehavioral deficits, must be educated in regular
mainstream schools (“inclusive education”)
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20. Treatment of SpLD
• Remedial Education to begin during primary schooling
• Given by Remedial Teacher
• Hourly one to one sessions thrice weekly for few years
• Systematic and highly structured training exercises
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21. • Management of SpLD in secondary school is based more on
providing provisions / accommodations:

exemption from spelling mistakes

availing extra time for written tests
 dropping a second language for work experience

dropping algebra and geometry for lower grade of mathematics &
work experience
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22. Treatment of ADHD
• Children with ADHD need psychiatric consultation for
counseling, behavior modification, and / or medications,
(methylphenidate or atomoxetine)
• Medications have been shown to be effective in significantly
reducing symptoms of inattention, impulsivity and
hyperactivity
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23. • Children with emotional problems need counseling sessions with a
child psychologist / psychiatrist
• Medications (anxiolytics, antidepressants) may be needed
• Parents of children with “language barrier” counseled to educate
their children in their own language medium schools or to attend a
facility for “language stimulation”
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24. Prevention of Poor School Performance
• Teachers trained to suspect emotional problems, SpLD, and
ADHD so that they are diagnosed and treated early
• School feeding programs (mid-day meal)
• Regular vision and hearing screening camps in schools
• Good sleeping habits
• Alleviation of poverty
• Proper ante-natal and peri-natal services
• Exclusive breastfeeding up to 6 months
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25. Thank You
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