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. Sunil Karande 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 Forum for LD 20132

3. Sunil Karande 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 Forum for LD 20133

4. Sunil Karande Medical Problems Preterm birth Low birth weight Malnutrition Worm infestation Hearing impairment (e.g. otitis media) Visual impairment (e.g. refractive error) Forum for LD 20134

5. Sunil Karande Medical Problems Asthma Allergic rhinitis Epilepsy (& AEDs) Cerebral Palsy Leukemia Thallasemia major Hemophilia Diabetes Mellitus Hypothyroidism Sleep disordered breathing (habitual snoring) Forum for LD 20135

6. Sunil Karande 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 Forum for LD 20136

7. Sunil Karande 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 Forum for LD 20137

8. Sunil Karande 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 Forum for LD 20138

9. Sunil Karande ~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 Forum for LD 20139

10. Sunil Karande 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 Forum for LD 201310

11. Sunil Karande 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 Forum for LD 201311

12. Sunil Karande 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 Forum for LD 201312

13. Sunil Karande 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 Forum for LD 201313

14. Sunil Karande 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) Forum for LD 201314

15. Sunil Karande 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 Forum for LD 201315

16. Sunil Karande Environmental causes Noisy environment Unattractive schools Too much television viewing (lack of sleep) Exposure to lead Forum for LD 201316

17. Sunil Karande 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 Forum for LD 201317

18. Sunil Karande Multidisciplinary approach Pediatrician Ophthalmologist Otolaryngologist Counselor Clinical Psychologist Child Psychiatrist Special Educator Forum for LD 201318

19. Sunil Karande 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”) Forum for LD 201319

20. Sunil Karande 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 Forum for LD 201320

21. Sunil Karande 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 Forum for LD 201321

22. Sunil Karande 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 Forum for LD 201322

23. Sunil Karande 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” Forum for LD 201323

24. Sunil Karande 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 Forum for LD 201324

25. Sunil Karande Thank You Forum for LD 201325