Dealing with learning problems

Nagalakshmi Balakrishnan

Banu Rekha Balaji has been an occupational therapist in Ireland for more than 10 years. As a public health service therapist in Dublin, she worked in Acute Psychiatry for three years and moved to Child and Adolescent Psychiatry in Cork, Ireland in 2006.

As part of a team, apart from assessing and treating children, she helps parents deal with extreme behavioural difficulties. She also does workshops for parents and teachers within the niche of Child and Adolescent Mental Health.

Through education, training, and advice, she wants to bring her experience to India, and plans to conduct workshops for parents and teachers here to help them create support systems for their children. Her current focus is on children who are in mainstream schools and struggle in this setting for any reason. More than medicine, her approach is from the point of view of education. Here, she speaks to Teacher Plus.

You interact with students, teachers, and parents to address a learning problem. How do you bring them together on the same platform?
In my opinion, a learning problem is not necessarily a question of a child’s actual academic performance. It also encompasses the tasks required for learning to happen, which involve sitting still, paying attention, being able to follow instructions, copying from the blackboard – I mean writing speed and legibility as well here – participating in class discussions, social interactions and more. I need to look at the child in entirety, in all the contexts of home, school, and play. I speak to the parents, the child, and the teachers and observe the child and the teacher in class and in the school yard. I then compile a report and meet with the parents and teachers to discuss and help them arrive at realistic goals.

Charting out realistic goals is what brings it all together. The teacher might say, ‘I want the child to listen when I talk.’ If I have observed fidgety behaviour and a lot of movement, I know that the child is sensory-seeking and is not actually able to sit and listen. It is then my job to bring it to the teacher’s attention that it’s a problem that needs to be worked out in a different way. This may include giving that child a movement break from time to time, using sensory equipment like a move-and-sit cushion in class, and acknowledging that the child is actually listening even if he is moving. Yes, research shows that children pay more attention when they move!

I also have a good sense of what the child’s home routine is as I have interviewed the parents. If there is lack of sleep or exercise, attention and concentration is always a problem, and learning is difficult. I address this also at a separate meeting with the parents.

Have you seen a particular learning problem recur in certain age groups? How do you deal with it?
Most referrals coming into our services query ADHD (Attention Deficit Hyperactivity Disorder), but only a few are given the diagnoses as more often than not, the underlying problems are developmental – either speech and language delays, co-ordination disorders or poor cognitive abilities, or specific ones like dyslexia. Psycho-social factors such as home environment (poor routines, absent parents, acrimonious relationships) or school-based such as bullying also play a big role.

Using a pencil grip to improve handwriting.
In the younger years, the learning difficulties are tied to developmental delays. The child may not be actually ready for school. For example, the average age for a child to understand and draw a circle is four. They shouldn’t be starting the alphabet then at age three. Imagine a child further disadvantaged developmentally, and this would lead to learning difficulties. More often than not, emotional and behavioural difficulties would be there as well.

During the later years, this is compounded by all the social nuances that become important. You would see that a child who is unable to learn these social norms is either withdrawn or lacks boundaries.

In the later teen years, I have seen children who inflict self-harm, manifest suicidal ideation, drop out of school, have eating disorders, or even psychosis. When we get a background history, we find that about 90 per cent are children who had struggled in school, and their problems were not addressed when they were younger.

Encouraging writing activities on different planes to improve shoulder stability required for handwriting.
When a child faces difficulty in learning, what is the first step that a parent or teacher needs to address?
Look at the child in her natural environment – the home and school – and try and tease out what could be going wrong for the child. Any child is developmentally geared towards progress. There is no child that does not want to learn – she/he is probably just not able to because of something that is going on around her. There is a hierarchy of needs that every human being is influenced by – if you are hungry, you cannot work. Look at the child’s basic needs:
Is she/he getting enough sleep, exercise, and nutrition?
Does she/he feel safe in her/his environment?
Does she/he feel that she/he is a part of the family or school?
Does she/he feel good about herself/himself?
Abraham Maslow’s hierarchy of needs defines very clearly what a human being needs to progress to the next level.

How can a parent or teacher identify a psychological problem? How many parameters would they need to find one?
Psychological problem is not a term I would use. It tends to say that there is something wrong with the child and that the child needs to be fixed. The child acts on his environment to the capacity of his own developmental abilities. A cognitively challenged child may have emotional maturity. Also, an academically bright child may be immature emotionally. The team I work with defines it as an Emotional Behavioural Disorder and it is charted in the ICD 10* that psychiatrists use, which means it’s a diagnosis. The challenge is to detect WHY that emotional behavioural disturbance is happening.

In a classroom of about 50 children, how can a teacher deal with different kinds of learning problems?
This is where the Indian system fails the child – 50 is too many, it’s a drain on the teacher. A smaller class size is what I would recommend, or having multiple teachers in the same class. It is important to acknowledge that every child learns in his or her own way and pace. If we cannot acknowledge that, we fail the child.

However, there are certain strategies one can use to manage a large classroom.

  • Using multi-sensory modalities – visual aids with the auditory, and projects that children make or do. This makes learning an interactive experience.
  • Having a clear behavioural system in class which promotes positive behaviour as opposed to punishment. Example, star of the week, golden time, etc., to children who manage to perform well. Golden time is time earned by the child to engage in structured or free play or other fun activity in class. It is important to reward even small gains made by a child with difficulty. Rewarding a child who is bright and able will not promote any positive behaviour from a child with difficulty. However, if a child with difficulty has shown he has been listening and doing his work even for a small period of time during the day, it needs to be acknowledged and rewarded. This will ensure that positive behaviour is repeated. Most often, I recommend teachers have a separate star chart for the child with a problem in addition to the reward system they are using for the whole class. Rewards should be simple things like getting extra time on the computer, reduced homework, etc.
  • Have the child with a problem sit close to the teacher – this is especially helpful if the child is of the type who can be easily distracted.
  • Consider the fact that most children have poor attention span anyway. Doing a quick movement activity every 20 minutes into the class increases attention.

Finding the right challenge in the child’s own natural environment and encouraging social skills too!
What kind of role should a counsellor play in a school? How much should a teacher rely on the counsellor?
I don’t recommend counsellors in primary schools. A school would need a psychologist who has access to a developmental team. The purpose of this is that most children have a developmental need that hampers learning and behaviour and it is important to find the underlying cause. Example, speech and language delays would need a speech and language therapist’s involvement; handwriting difficulties would need occupational therapy. A counsellor can only lend a listening ear which is useful in a secondary school setting when children can verbalize their difficulties.

At what point do medicine and therapy come together in a classroom?
Medication is valuable for a short period of time to alleviate distress. But medication only acts on certain aspects, for example, attention span or mood. It does not make changes to behaviour or family dynamics which play a huge role in sustaining a child’s progress. So medication that is prescribed with caution needs review, whilst therapy is on-going.

Swinging helps vestibular and auditory processing. It means that a child who doesn’t like movement or noises is able to process them better. Such children have anxiety and show improvement after these activities are incorporated.
How do you plan to bring your expertise into India?
The educational system here does no great favours to the child who struggles even a little. If I am able to bring even some understanding of that to parents and teachers, it would be great.

I would like to create a shift in how we view the child and his development. We are looking at a small person who has a multitude of talents that is unique. And not all pegs fit a square hole. Hammering that peg to fit into our pre-designed hole only destroys the peg. Research in Infant Mental Health suggests that children absorb more than we realize from a very early age, and not all that learning is cognitive – a lot of it is emotional and learning to cope with psychosocial factors. The case studies clearly indicate that psychological profiles of children are complex and require an in-depth assessment before ‘labelling’ the child.

It is important for a child to feel valued and have good self-esteem to grow into a well-adjusted adult. In this fast moving age of technology, parents and teachers will have to learn to influence the child in a positive way.

There is also a lot of misconception in the society about labels such as ADHD, developmental milestones (example – he will start to speak once he starts school!) and also about the western concepts that are thrown in for good measure. For example, one parent said that positive parenting cannot possibly work, as you cannot praise and reward your child for everything. She was right and wrong. It’s true that constantly praising and rewarding is damaging, but that is not what positive parenting is about. Positive parenting is about engagement, being clear with boundaries and rule, having realistic consequences and rewarding desirable behaviour.

Case study: Rob’s story*

Rob was referred to the Department of Child and Adolescent Psychiatry by his general physician with a covering letter from his school. He was six years old at the time of this referral and the complaint was inattention and lack of concentration, aggressive behaviour towards his classmates and inability to socialize appropriately with his peers.

Initial assessment
The Child and Adolescent Psychiatrist met Rob’s mother to get a picture of his early history, family history and the mother’s expectations from the service. During this meeting, Rob’s mother was clear that the school had pushed her into bringing Rob to our service and though Rob’s behaviour was sometimes difficult for her to manage, she was able to cope. Rob’s father attended this meeting as well, and he said he did not think that Rob had any difficulties. The parents had been separated since before Rob’s birth. There was indication that Rob could have Sensory Processing Disorder and the occupational therapist was asked to step in to complete the evaluation.

School visit
A school visit was organized where the occupational therapist observed Rob in his classroom and in the playground and met with his teacher, principal, and learning support teacher (learning support is provided to children who cannot cope academically and it is provided individually or in small groups). The classroom was a busy environment, very bright and noisy. Rob was noted to be moving and fidgeting constantly and was unable to engage with other children during group work.

At this stage I left the school and Rob’s mother with a sensory based program comprising heavy work and movement activities spread through the day to manage his sensory-seeking.

At a review meeting, Rob’s mother expressed concerns that while Rob visited with his father at the weekends, his language would get fouler, he would be more aggressive and that his behaviour was harder to manage. An appointment was sent out to Rob’s father to explore this issue further. The social worker on the team was asked to be a part of this meeting to assess if there were child protection issues. At the end of the meeting, it was clear that the parents’ relationship was acrimonious and this was having an impact on Rob and his behaviour. Currently, the parents are engaging on a Parenting Together program at the department so that they can parent consistently without letting their own relationships impact the child. A recent phone call to the school indicated that Rob had made progress academically. He still struggles socially, but the aggressive incidents have significantly reduced.

At this juncture, the psychiatrist has held off confirming a diagnosis of ADHD given the context of Rob’s psychosocial environment and will review him after the parents have completed the parenting program.

Pre-writing activities

Case study: Harry’s story*

Harry was admitted to the inpatient Child Psychiatry unit at the age of 14 on account of violent episodes with paranoia. He had taken a hurley (a kind of bat) and broken the furniture in his home when his father had reprimanded him for not doing his homework. Prior to this incident, Harry had had a number of warnings and suspensions in school. It was reported by the school that he was mixing with the wrong crowd and possibly smoking cannabis and inhaling aerosols. He was discharged from the inpatient unit within a week as the cause of his violence was drug-induced and he was referred to community services.

Harry was allocated psychology, speech and language therapy and occupational therapy for assessment and intervention. The psychologist worked with Harry to set goals and help with solving his problem, and met regularly with the parents to support them in parenting Harry through this stormy time. The parents also attended a 12-week program called Strengthening Families along with Harry and his two siblings. This program looked at communication within the family and helped to rebuild their fractured relationships.

In the meanwhile, the speech and language assessment indicated a moderate receptive language impairment which meant that Harry was unable to understand all that was being said by the people around him. He came across as a bright and articulate young man as his expressive language was in the above average range. In addition to this, the occupational therapy assessment indicated severe impairment with his visual perceptual component – meaning, words, and pictures would take time to make sense to him. To summarize, the classroom was a very stressful place for Harry and he took it out at home.

A school meeting was organized and these issues were explained to the teachers. Harry was given access to a laptop with the Read and Write Gold program* which meant he could dictate a lot of his work and electronically save lectures and notes.

*The names have been changed to maintain confidentiality.

*ICD 10: The International Classification of Diseases (ICD) is the standard diagnostic tool for epidemiology, health management and clinical purposes. This includes the analysis of the general health situation of population groups. It is used to monitor the incidence and prevalence of diseases and other health problems.

*Read & Write 11 Gold is a toolbar that “floats” on top of any open application. Assistance can then easily be called upon as the user works.It brings comprehensive literacy support for the user with literacy or learning difficulties. It allows pages from a book or magazine to be scanned and read by the computer. It also includes word prediction, as the user is typing. It allows users to work in a truly inclusive environment using standard Windows applications. Read & Write Gold will also read PDF documents.

The interviewer is Executive Editor, Ratna Sagar P Ltd. She can be reached at . Banu Rekha Balaji can be reached at brbiyer@gmail.com.