APPROACH TO A CHILD WITH SCHOLASTIC BACKWARDNESS
Dr. Nandini Mundkar*
Consultant Developmental Pediatrician, Centre for the child Development and disability, Bangalore. Email : bchrc@vsnl.com*
Poor scholastic performance is a common problem faced by schools, parents and physicians. It is estimated that 5-15% of school-going children suffer from scholastic backwardness. The human and financial costs of academic failure are extremely high. Unrecognized and unremediated, scholastic backwardness has a lifelong impact on the child, affecting school completion, higher education, interpersonal relationships, prospects for employment, marriage etc.

Early recognition and adequate remediation is important and can make a big difference to the child's future. Medical practitioners are in an ideal position to help families identify the problem early and to provide appropriate guidance. Awareness of the causes, varying methods of presentation and principles of management are essential for all physicians dealing with children on a regular basis.
Etiology
The etiology of learning problems is diverse. The etiologies and their prevalence in the total population are: learning disabilities, 7 to 10 percent; emotional disturbances, 5 to 10 percent; attention-deficit/hyperactivity disorder (ADHD), 3-5 percent; chronic illness, 5 percent; and mental retardation, 2 to 3 percent. Many of these factors may also be overlapping and coexistent. Apart from these, developmental disabilities such as hearing impairment, visual impairment, language disorders and environmental effects also contribute to learning difficulties in children and challenge vulnerable children further.
Risk factors for scholastic backwardness
1. Hearing impairment:
Hearing loss in childhood is associated with poor language development in early childhood and with lower educational achievement and employment opportunities later in life. Apart from those children suffering from profound hearing loss, conductive hearing loss is common in school age group as a result of recurrent, chronic or acute otitis media. These children experience communication difficulties under adverse listening conditions such as noisy classrooms. Such conditions might impair their educational performance even children with minimal hearing loss, unilateral hearing loss, are 10 times more likely than normal hearing children to suffer academic difficulties. They are more likely to experience grade repetition or require extra assistance in school.

Even children with minimal hearing loss, unilateral hearing loss, are 10 times more likely than normal hearing children to suffer academic difficulties

2. Visual impairments:
Visual impairment caused by refractive error, amblyopia, strabismus, and astigmatism is a common condition among young children, affecting 5 percent to 10 percent of all preschoolers. Amblyopia is present in 1 percent to 4 percent of preschool children; and estimated 5 percent to 7 percent of preschool children have refractive errors. Uncorrected amblyopia may harm school performance, ability to learn, and later, adult self-image. Children with visual impairment may present with certain features such as deterioration in handwriting, slowness in copying from the board, deterioration in activities dependent on eye hand coordination and asking for written instructions to be given verbally. Even though these children make progress within the curriculum, they progress at lower levels than expected, exhibit fatigue and frustration towards the end of the school day.

3. Prematurity, low birth weight
Research has consistently demonstrated a greater risk for learning-related problems in preterm, low birth weight children. There is clear evidence to show significantly poorer cognitive and academic outcomes in children born preterm and/or with low birth weights compared with children born full term.

There is clear evidence to show significantly poorer cognitive and academic outcomes in children born preterm and/or with low birth weights compared with children born full term.

Many preterm infants exhibit early cognitive and learning problems that present as expressive language delays, visual-motor and visual-spatial deficits, and/or attentional difficulties during the first few years of life. These early deficits are believed to be associated with later academic and learning problems. When premature, low birth weight children reach school age, they exhibit a higher rate of learning disabilities and lower scores on tests of reading, writing, math, spelling, and executive functioning. Bhutta et al conducted a meta-analysis of studies examining school-age children born preterm and found that preterm children exhibited significantly lower IQ scores than full-term controls.

4. Medical factors:
Several medical problems in the child contribute to learning problems. This may the direct effect of the condition itself, or due to effects leading to recurrent school absenteeism, adverse effects of medication, poor self esteem affecting motivation and performance. Concentration deficits, inattentiveness, impaired short-term memory, poor time management (decreased psychomotor functioning), mood change and fatigue, may cause functional impairment of academic and psychosocial functioning.
Common chronic conditions such as asthma, allergies, repeated otitis media, lead poisoning, cancer, epilepsy, cerebral palsy and type 1 diabetes mellitus and hypothyroidism are known to be associated with poor academic performance. For e.g., factors that may contribute to poor school performance among children with asthma include iatrogenic effects of oral steroids, poor medical management of the disease, and psychological problems Obstructive sleep apnea affects 1-10% of children. OSA often results from adenotonsillar hypertrophy, neuromuscular disease and craniofacial abnormalities. Behavioral problems, inattentiveness and poor academic performance are seen in children with habitual snoring and sleep apnea.

5. Neurodevelopmental disorders
SPECIFIC LEARNING DISABILITY: Specific learning disabilities (SpLD) viz. dyslexia, dysgraphia and dyscalculia is a generic term that refers to a heterogeneous group of disorders manifested by significant unexpected, specific and persistent difficulties in the acquisition and use of reading (dyslexia), writing (dysgraphia) or mathematical (dyscalculia) abilities despite conventional instruction, average or above average intelligence, proper motivation and adequate socio-cultural opportunity. The term SpLD does not include children who have learning problems which are primarily the result of visual, hearing, or motor handicaps, of subnormal intelligence, of emotional disturbance, or of socio-cultural disadvantage. SpLD are presumed to be due to central nervous system dysfunction. They constitute an invisible handicap and are important causes of poor school performance in children. SpLD is both familial and heritable. Very often a clear cause of LD cannot be identified.

ADHD: Attention-deficit/hyperactivity disorder (ADHD) is one of the most common childhood-onset neurodevelopmental disorders. According to the Diagnostic and Statistical Manual of Mental Disorders IV (DSM-IV), the prevalence of distinguished by symptoms of inattention, hyperactivity, and impulsivity. ADHD may be accompanied by learning disabilities, depression, anxiety, conduct disorder, and oppositional defiant disorder. Recent estimates of learning disorders in children with ADHD range from 10% to 25%, (27) ADHD makes the individuals less available for learning because of the activity level, inattention, and/or impulsivity. Children with ADHD suffer from various combinations of impairments in functioning at school, at home, and with peers. School-based problems include lower than expected or erratic grades, achievement test scores, and intelligence test scores, caused by gaps in learned material, poor organizational and study skills, difficulty with taking tests due to inattention and impulsivity, or failure to complete or turn in homework assignments. Behavioral difficulties related to ADHD often lead to constant friction among the student, peers, the teacher, and the parents. The result may be special class placement, suspension, or expulsion.

Tourette syndrome: Tourette syndrome (TS) is a common, hereditary, neurobehavioral disorder of childhood. In the majority of TS patients, the disorder starts with ADHD and 2.4 years later develops motor and vocal tics. TS patients had a significantly increased frequency of attending classes for the educationally handicapped, placement in classes for the severely emotionally disturbed, attending any special classes, severe test anxiety, stuttering, letter, number or word reversal, reading very slowly and poor retention of material read.

Slow learners: Children with an IQ range of 70-89 are classified as slow learners. Slow learners are considered neither learning disabled nor mentally retarded, students with below average cognitive abilities who are not disabled, but who struggle to cope with the traditional academic demands of the regular classroom. Eight to Nine percent of primary school children score below average in standard IQ tests. Slow learners show the following characteristics that impair their academic performance: poor reasoning ability, short attention span, and poor retention: poor motivation and work habits; poorly developed language and communication skills; lack of confidence, lack of academic success, especially in reading; low power of retention and memory; reduced ability to make abstractions; anxiety and fear of failure; poor self-concept; and poor organization.

Children with an IQ range of 70-89 are classified as slow learners.

Mental retardation: Children with mental retardation have a significantly sub average general intellectual functioning, with IQ below 70. There is a generalized learning deficit differing from specific learning disability such as dyslexia, which is significant in severity. Such children also exhibit impairments in adaptive behavior, self care and communication and mobility. The prevalence of mental retardation is 3% of the general population. Most children with MR are recognized before the first years of school. The common genetic causes of MR include Down's syndrome, Fragile X, and Klinefelter's syndrome. Whatever the etiology, all of them cause varying degrees of impairment in language development, short term memory deficits, low attention span and behavioral problems and a severe learning difficulty.

Risk factors / causes of learning disabilities
Medical risk factors
Prematurity and sequelae
Low birth weight
Chronic illnesses
Congenital infections
Malignancies / radiation and chemotherapeutic effects
Lead poisoning
Subclinical seizures

Genetic and endocrine disorders
Turner syndrome
Fragile X syndrome
Williams syndrome
Hypothyroidism
Klinefelter's syndrome
Congenital adrenal hyperplasia
PKU

Medication effects
Methylxanthines
Corticosteroids>
Anticonvulsants
Antihistamines
Ethanol and recreational drugs

Neurodevelopmental disorders
Specific learning disability
ADHD
Autism spectrum disorders
Speech and language disorders
Cerebral palsy
Mental retardation

Emotional disorders
Anxiety
Depression
Mood disorders
Post-traumatic stress disorders
Other psychiatric disorders

Environmental factors
Lack of motivation, role models
Uninteresting curricula, rote learning
Poor study skills
Language barrier education in English medium schools
Poor socio-economic conditions

Language disorders
From 1% to 13% of the population have either a developmental expressive or receptive language disorder. Some 3% to 5% of children have a developmental expressive language disorder (DSM IV), the majority of which are the developmental type with a childhood onset. DSM-IV suggests that a mixed expressive language disorder may be present in 3% of school-age children. As most learning takes place in schools through the medium of language, children with language disorders struggle in school. Children with early language disorder, even if they develop normal language competence later in life, are at risk for learning disorders. The Iowa longitudinal study found that early language status has long term effects on school performance. Children with poor language show persisting needs for special education services, indicating poor levels of class room performance. Research shows that 50-60% children who enter school with poor language have later difficulties in school.

Autism spectrum disorder
Autism exists with any level of intelligence, but many individuals with autism suffer also from learning disability. The core features of autism - social, emotional, communication and language deficits interfere at all levels learning and psychosocial functioning. Short attention span, hyperactivity, poor organization and difficulty in generalizations, further compromise academic performance in autistic children.
Poor school performance does not always indicate a learning disorder. Emotional and environmental factors by themselves can affect learning, but evaluating the contribution often is not simple. Emotional disorders such as anxiety, obsessive-compulsive, mood disorders, depression, and psychosomatic disorders are common in children. Conduct disorders, oppositional defiant disorders etc are also seen in children frequently and may occur as comorbid with ADHD. Children with emotional problems exhibit hyperactivity, poor attention span, impulsivity, learning difficulty, performing below grade level and poor coping skills.

Other factors
Poor school performance may also be due to environmental factors such as lack of adequate facilities for studying, adverse family situations, lack of encouragement for studying and lack of role models. Other factors include prior educational experience of the child, overcrowded classrooms, language barrier education in English medium schools, unrealistic academic expectations by parents and school, uninteresting curriculum, rote based learning methods and poor study skills result in lack of motivation and disinterest in academic achievement.

Role of the pediatrician in the child with scholastic backwardness
In evaluating a child with poor academic performance, a framework of approach and a multidisciplinary assessment is very helpful. Children with learning problems may present with a wide spectrum of complaints ranging from not coping with academics, failure or dislike of writing, school refusal, and psychosomatic complaints to behavioral and emotional problems. Symptoms may present at any age from primary school level right up to adolescence. Children with early language delays are particularly at risk of learning difficulties. Aggression, oppositional or defiant behavior in class, truancy and high risk behaviors like smoking and substance abuse should be taken very seriously and learning disorders considered and ruled out in such children.

Children with learning problems may present with a wide spectrum of complaints ranging from not coping with academics, failure or dislike of writing, school refusal, and psychosomatic complaints to behavioral and emotional problems.

As in any other medical condition, a thorough history is essential. History helps to understand the evolution of the problem, its severity, identify medical factors that may be contributing to the problem, medications, impact on the child, and family. Even though the process may be time consuming, developmental history with particular reference to language and fine motor skills, school history, behavior, sleep, appetite, family and environmental factors must be probed into. An interview with the child sometimes provides great insight into the family dynamics. Complete description of the child's difficulties in reading, writing, spelling and arithmetic, attention, distractibility, friendship, social interaction and peer relationships, adjustment to school, review of the child's workbooks, asking the child to read or examining the child's handwriting is extremely helpful in diagnosis.

Physical and neurological examination is mandatory to rule out any treatable conditions. Most children may not have any noteworthy abnormalities on physical or neurological examination except for soft neurological signs such as motor incoordination, overflow movements and mirror imaging.

The pediatrician's role then is to make appropriate referrals as necessary to the ENT specialist, ophthalmologist to rule out impairments in hearing and vision and treat accordingly. Iron deficiency anemia, thyroid disorders, nutritional problems have to be identified and treated. Referred to psychiatrist may be need in severe emotional problems, Tourette's syndrome or if other psychiatric disorders are suspected.

At the end of the history it is possible to conclude whether a child has a learning difficulty or not. When learning difficulty is apparent, referrals are made for appropriate psycho educational evaluation. A good psycho educational evaluation consists of IQ assessment using standardized tests such as WISC Indian adaptation or Binet Kamat, speech and language evaluation, educational and functional level of the child. DSM IV criteria are commonly used to evaluate symptoms of ADHD.
Management
Once the diagnosis is made, management depends on the cause of the learning difficulty. Medical conditions contributing to learning problems have to be treated appropriately and satisfactory control established in conditions such as asthma, IDDM, hypothyroidism, epilepsy etc. Parent education is very essential to maintain satisfactory control and compliance in such children.

Children diagnosed as specific learning disability require remedial education depending on their level of difficulty. Specific and highly structured instructions based on the principles of phonetics remediate reading and spelling difficulties. Arithmetic is an area of concern in many children and this has to be addressed. Remedial help is started as soon as possible. A multidisciplinary team may be essential including speech and language therapist, special educator and occupational therapist. An individual education plan is drawn up keeping in mind the child's needs and level of functioning. Remedial work has to be carried out regularly and consistently until the child reaches the appropriate level. This may take several months to years. Support from the school teachers is essential for children with learning difficulties. Simple supportive measures from the teachers such as preferential seating of the child in front of the class, permission to photocopy notes, extra time for project submission and tests, and less home work may be requested and will go a long way in helping the chills with learning difficulties.

Simple supportive measures from the teachers such as preferential seating of the child in front of the class, permission to photocopy notes, extra time for project submission and tests, and less home work may be requested and will go a long way in helping the chills with learning difficulties.

Children diagnosed as ADHD are treated with behavior modifications medications and remedial education if there is a co morbid SpLD.

Parent counseling about the nature of the problem and its impact is essential. Parents need help and counseling on appropriate educational placements for their child, to have realistic educational expectations and behavioral management, Facilities and concessions available for children with learning difficulties such as second language exemption, extra time for exams, and calculators for math may not be known to them.

Periodic monitoring and review is essential to make sure that the child is receiving the appropriate services, and making satisfactory progress. Learning problems in children are chronic problems. Continued support, intervention and monitoring are essential to ensure best outcome for the child.
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