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” ~20% of children in a classroom get poor marks - they are “scholastically backward” “Symptom” reflecting a larger underlying problem in children “Symptom” reflecting a larger underlying problem in children Results in child having a low self-esteem Results in child having a low self-esteem Significant stress to parents Significant stress to parents

3. Sunil Karande Causes of Scholastic Backwardness Medical problems Medical problems Below average intelligence Below average intelligence Specific learning disability (SpLD) Specific learning disability (SpLD) Attention-deficit hyperactivity disorder (ADHD) Attention-deficit hyperactivity disorder (ADHD) Emotional problems Emotional problems Poor socio-cultural home environment Poor socio-cultural home environment Psychiatric disorders Psychiatric disorders Environmental causes Environmental causes

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

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

6. Sunil Karande Below average intelligence Intelligence (measured as IQ score): most important prognostic variable Intelligence (measured as IQ score): most important prognostic variable Borderline intelligence or “slow learners” (IQ 71 to 84) Borderline intelligence or “slow learners” (IQ 71 to 84) Mental retardation (IQ ≤ 70) e.g. Down syndrome Mental retardation (IQ ≤ 70) e.g. Down syndrome Risk factors: prematurity, meningitis, severe head injury Risk factors: prematurity, meningitis, severe head injury Usually have history of delayed milestones Usually have history of delayed milestones

7. Sunil Karande SpLD heterogeneous group of disorders 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 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 despite conventional instruction, normal intelligence, proper motivation and adequate socio-cultural opportunity

8. Sunil Karande What happens in dyslexia? Deficits in phonologic awareness Deficits in phonologic awareness “Phoneme”: smallest discernible segment of speech “Phoneme”: smallest discernible segment of speech "bat" consists of three phonemes: "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 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

9. Sunil Karande ~5-12% school children have dyslexia ~5-12% school children have dyslexia Red flags for 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) (trouble playing rhyming games with words, or confusing words that sound alike) * positive family history

10. Sunil Karande Symptoms of SpLD Children with SpLD fail to achieve school grades at a level that is commensurate with their intelligence 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 Repeated spelling mistakes, untidy or illegible handwriting with poor sequencing, inability to perform simple mathematical calculations correctly Life-long condition Life-long condition

11. Sunil Karande ADHD ADHD affects 8-12% of children ADHD affects 8-12% of children Results in inattention, impulsivity and hyperactivity Results in inattention, impulsivity and hyperactivity Some have predominant inattention, some have, impulsivity and hyperactivity, some have both Some have predominant inattention, some have, impulsivity and hyperactivity, some have both At risk for poor school performance At risk for poor school performance 20-25% of children with ADHD have SpLD & vice versa 20-25% of children with ADHD have SpLD & vice versa

12. Sunil Karande Autism Impairment of reciprocal social interactions Impairment of reciprocal social interactions Impaired communication skills Impaired communication skills Restricted range of interests or repetitive behaviors Restricted range of interests or repetitive behaviors Demonstrate distress and oppositionality when exposed to requests to complete academic tasks Demonstrate distress and oppositionality when exposed to requests to complete academic tasks

13. Sunil Karande Tourette syndrome Starts with ADHD Starts with ADHD 2.4 years later develop motor and vocal tics 2.4 years later develop motor and vocal tics Have learning problems: SpLD, ADHD, ODD, CD Have learning problems: SpLD, ADHD, ODD, CD

14. Sunil Karande Emotional Problems Chronic neglect Chronic neglect Sexual abuse Sexual abuse Parents getting divorced Parents getting divorced Losing a sibling Losing a sibling Chronic health impairments Chronic health impairments Resulting in low self-esteem & loss of motivation to study

15. Sunil Karande Poor socio-cultural environment Language barrier Language barrier Malnutrition due to poverty Malnutrition due to poverty Low education status of parents Low education status of parents Parental attitudes which do not motivate them to study Parental attitudes which do not motivate them to study Unsatisfactory home environment (domestic violence, family stressors, adverse life events) Unsatisfactory home environment (domestic violence, family stressors, adverse life events)

16. Sunil Karande Psychiatric disorders Early signs of emerging or existing anxiety, depression or psychosis Early signs of emerging or existing anxiety, depression or psychosis Conduct disorder and oppositional defiant disorder Conduct disorder and oppositional defiant disorder Change in child’s personality Change in child’s personality Deteriorating school performance Deteriorating school performance

17. Sunil Karande Environmental causes Noisy environment Noisy environment Unattractive schools Unattractive schools Too much television viewing (lack of sleep) Too much television viewing (lack of sleep) Lead exposure Lead exposure

18. Sunil Karande Management of Poor School Performance Child may be having ≥1 reason Child may be having ≥1 reason Refer early for evaluation Refer early for evaluation Information from parents, classroom teachers & school counselor crucial Information from parents, classroom teachers & school counselor crucial Information should clearly describe child’s academic difficulties, behavior & social functioning Information should clearly describe child’s academic difficulties, behavior & social functioning

19. Sunil Karande Multidisciplinary approach Pediatrician Pediatrician Ophthalmologist Ophthalmologist Otolaryngologist Otolaryngologist Counselor Counselor Clinical Psychologist Clinical Psychologist Child Psychiatrist Child Psychiatrist Special Educator Special Educator

20. Sunil Karande Treatment If any specific ‘medical’ reason identified, pediatrician should treat it as effectively as possible If any specific ‘medical’ reason identified, pediatrician should treat it as effectively as possible e.g. optimum control of asthma or epilepsy e.g. optimum control of asthma or epilepsy Correction of hearing and/or visual impairment 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”) Children irrespective of their physical, sensory, or neurobehavioral deficits, must be educated in regular mainstream schools (“inclusive education”)

21. Sunil Karande Treatment of SpLD Remedial Education to begin during primary schooling Remedial Education to begin during primary schooling Hourly one to one sessions thrice weekly for few years Hourly one to one sessions thrice weekly for few years Systematic and highly structured training exercises Systematic and highly structured training exercises a) to learn that words can be segmented into smaller units of sound “phoneme awareness”, and that these sounds are linked with specific letters and letter patterns “phonics” a) to learn that words can be segmented into smaller units of sound “phoneme awareness”, and that these sounds are linked with specific letters and letter patterns “phonics” b) Practice in reading stories; both to apply newly acquired decoding skills to reading words in context and to experience reading for meaning

22. Sunil Karande Management of SpLD in secondary school is based more on providing provisions / accommodations rather than remediation: Management of SpLD in secondary school is based more on providing provisions / accommodations rather than remediation:  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

23. Sunil Karande Treatment of ADHD Children with ADHD need psychiatric consultation for counseling, behavior modification, and / or medications, (methylphenidate or atomoxetine) 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 Medications have been shown to be effective in significantly reducing symptoms of inattention, impulsivity and hyperactivity

24. Sunil Karande Children with TS need psychiatric medications for their verbal/motor tics and co-morbidities Children with TS need psychiatric medications for their verbal/motor tics and co-morbidities Children with emotional problems need counseling sessions with a child psychologist / psychiatrist Children with emotional problems need counseling sessions with a child psychologist / psychiatrist Medications (anxiolytics, antidepressants) may be needed 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” 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”

25. Sunil Karande Prevention of Poor School Performance Teachers trained to suspect emotional problems, SpLD, and ADHD so that they are diagnosed and treated early Teachers trained to suspect emotional problems, SpLD, and ADHD so that they are diagnosed and treated early School feeding programs (mid-day meal) School feeding programs (mid-day meal) Regular vision and hearing screening camps in schools Regular vision and hearing screening camps in schools Good sleeping habits Good sleeping habits Alleviation of poverty Alleviation of poverty Proper ante-natal and peri-natal services Proper ante-natal and peri-natal services Exclusive breastfeeding up to 6 months Exclusive breastfeeding up to 6 months

26. Sunil Karande Thank You