Poor School Performance

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 Sunil Karande

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

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

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

6. Below average intelligence • Intelligence (measured as 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 Sunil Karande

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 Sunil Karande

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 Sunil Karande

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 Sunil Karande

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 Sunil Karande

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 Sunil Karande

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 Sunil Karande

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

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

15. 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) Sunil Karande

16. 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 Sunil Karande

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

18. 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 Sunil Karande

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

20. Treatment • 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”) Sunil Karande

21. Treatment of SpLD • Remedial Education to begin during primary schooling • Hourly one to one sessions thrice weekly for few years • 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” b) Practice in reading stories; both to apply newly acquired decoding skills to reading words in context and to experience reading for meaning Sunil Karande

22. 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 Sunil Karande

23. 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 Sunil Karande

24. 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 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” Sunil Karande

25. 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 Sunil Karande

26. Thank You Sunil Karande