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 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 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. 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 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. 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 Sunil Karande

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) Sunil Karande

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 Sunil Karande

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

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 Sunil Karande

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

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”) Sunil Karande

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 Sunil Karande

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 Sunil Karande

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 Sunil Karande

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” Sunil Karande

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 Sunil Karande

25. Thank You Sunil Karande