INTRODUCTION {#sec1-1}
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In India, 20%--50% of school-going children suffer from scholastic backwardness (SB).\[[@ref1][@ref2]\] The various causes for SB in children are medical problems, below average intelligence, specific learning disability, attention-deficit hyperactivity disorder, emotional problems, poor sociocultural home environment, psychiatric disorders, and environmental causes.\[[@ref3]\] Specific learning disorder (SLD) is an important cause of SB and affects 5%--10% of children worldwide.\[[@ref4]\] The prevalence of SLD in India ranges from 1.6% to 15%.\[[@ref5][@ref6][@ref7][@ref8]\]

In 2018, from Kerala, 20,000 differently-abled students appeared for the SSLC examination as compared to 18,240 students in 2017.\[[@ref9]\] In 2018, 5201 students have availed concessions for intellectual disability (ID) and 9785 students for SLD for SSLC examination.\[[@ref10]\]

We have observed an increase in the number of students, especially those in classes nine and ten, approaching for evaluation and certification of SB. Although Kerala is the most literate state in India, there is not much research available in this area. The diagnosis and assessment of SLD with its inherent complexities in a multilinguistic, resource-poor setting like India are a challenge. The differing classification, concepts, and implications of SLD in the medical/mental health and educational systems with its attendant complexities could also be the reason for a paucity of research.\[[@ref11]\] The diagnosis and management of SLD are thus a complex issue, and there is a lack of consensus, leading to difficulties in research. Nevertheless, research is needed to explore and address the multi-faceted muddy issues in this area in a utilitarian manner.

Therefore, we decided to study the sociodemographic, clinical, and academic profile of students approaching for the evaluation of SB and the causes of SB.

MATERIALS AND METHODS {#sec1-2}
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This study has a retrospective chart review design. The study was conducted in the psychiatry department of a Government Medical College, a tertiary care teaching hospital in Kerala. The department has the services of consultant psychiatrists, senior and junior residents, one clinical psychologist, and one psychiatric social worker.

Children and adolescents who are school-going students attending the psychiatry outpatient department with complaints of "difficulty in academics" were first screened by psychiatry residents/consultants. The youngsters were either referred by teachers or by parents. The cases evaluated by junior residents were discussed with qualified psychiatrists, diagnosed as per the Diagnostic and Statistical Manual of Mental Disorders, Fifth Edition criteria, and multimodal interventions planned. The mental health issues were assessed and appropriate interventions were done. Those who did not require the services of clinical psychologist were managed by the psychiatrists\' team. Those who required structured academic assessment were referred to clinical psychologist. Some of them would approach clinical psychologists outside the institution due to the long waiting period. This is the routine procedure adopted.

A retrospective chart review of evaluation of students aged 6--16 years, who had approached the clinical psychologist of the institution, for the structured assessment of SB, referred by the psychiatrists\' team, over 1 year from January to December 2016, was done.

The evaluation procedure adopted was as follows. After gathering detailed history from parents and evaluation report from teachers, intelligence tests were administered to all students. Intelligence was measured using either the Binet--Kamat Scale of intelligence or Malins Intelligence Scale for Indian Children. The assessment of SLD was done in students with average intelligence quotient (IQ-90-110) and above, using a combination of curriculum-based assessment and NIMHANS battery of SLD where suitable, as there are no standardized tests for SLD in Malayalam (vernacular language). The traditional ability-achievement discrepancy model was used for assessment due to reasons of feasibility. According to this model, the diagnosis of SLD is based on whether the child\'s scores showed a discrepancy between ability and achievement, usually assessed by comparing the child\'s IQ with the levels attained on an achievement test.\[[@ref12]\]

The academic issues of students with average intelligence, without SLD were further explored, for providing appropriate inputs. We categorized their learning difficulties as due to "poor learning style," poor learning habit, and environmental deprivation (ED). "Poor learning style" was defined operationally as "inappropriate way in which a student perceives, processes, and retains the information gathered," "poor learning habit" as "no regular study habit consistent with the age, class of study and the intellectual level of the child, leading to SBs," and "Environmental deprivation" was defined as "poor stimulation, stressors at school/home, and financial difficulties at home interfering with the academics of the child."

The study was approved by the Institutional Review board and Ethics Committee.

RESULTS {#sec1-3}
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The results were analyzed using descriptive statistics. A total of 207 cases were registered with the clinical psychologist for academic assessment during 1 year. Children in the age group 13--16 years were the majority (61.4%). Males outnumbered females (male: female ratio 1.58:1). Most were from a rural background (81.6%). More than half were from high school and 22% were in class 10^th^. Previous assessment for SB was done only in 12 (20%) of high school students. About 97% belonged to state syllabus and 90% studied in Malayalam (vernacular) medium. About 93.3% were referred by teachers and the rest by the parents \[[Table 1](#T1){ref-type="table"}\].

###### 

Socio academic variables of students (207) and parents

  Variable                      Categories          *n* (%)
  ----------------------------- ------------------- -------------
  Age (years)                   6-9                 52 (25.12)
  10-12                         28 (13.52)          
  13-16                         127 (61.35)         
  Gender                        Male                127 (61.35)
  Female                        80 (38.64)          
  Residence                     Rural               169 (81.64)
  Urban                         38 (18.35)          
  Class of study                LP                  58 (28.01)
  UP                            25 (12.07)          
  High school                   124 (59.90)         
  Syllabus of study             State (SSLC)        201 (97.10)
  CBSE                          6 (2.89)            
  ICSE                          0                   
  Others                        0                   
  Medium of instruction         Malayalam           186 (89.85)
  English                       21 (10.14)          
  Source of referral            Teachers            191 (92.27)
  Parents                       16 (7.72)           
  Educational level of mother   Primary             11 (5.31)
  High school                   125 (60.38)         
  Predegree                     52 (25.12)          
  Graduation and above          19 (9.17)           
  Educational level of father   Primary             37 (17.87)
  High school                   118 (57)            
  Predegree                     39 (18.84)          
  Graduation and above          13 (6.28)           
  Employment status of mother   Unskilled laborer   37 (17.87)
  Skilled laborer               51 (24.64)          
  Professional                  19 (9.17)           
  Unemployed                    100 (48.30)         
  Employment status of father   Unskilled laborer   108 (52.17)
  Skilled laborer               78 (37.68)          
  Professional                  18 (8.69)           
  Unemployed                    3 (1.44)            

LP -- Lower primary; UP -- Upper primary

The principal cause of SB was examined. Majority of the students who presented with "scholastic backwardness" were slow learners (34.8%). Slow learners are defined as "developmental profile consistently at the lower end of the normal range and IQ scores are below average range."\[[@ref13]\] We considered slow learners as students with below average intelligence (IQ-80--89) and borderline intelligence (IQ 70--79) \[[Table 2](#T2){ref-type="table"}\].

###### 

Principal diagnosis of scholastic backwardness (*n*=207)

  Categories of diagnosis                               *n* (%)
  ----------------------------------------------------- ------------
  ID                                                    58 (28.01)
  Slow learner                                          72 (34.78)
  SLD                                                   24 (11.59)
  ASD                                                   10 (4.83)
  ADHD-combined type                                    6 (2.89)
  ADHD-predominantly inattentive type                   4 (1.93)
  Conduct disorder                                      7 (3.38)
  Other psychiatric disorders                           1 (0.48)
  Other behavioral problems not amounting to disorder   4 (1.93)
  Nil diagnosis                                         21 (10.14)

ASD -- Autism spectrum disorder; SLD -- Specific learning disorder; ADHD -- Attention-deficit hyperactivity disorder; ID -- Intellectual disability

This was followed by students with ID -- 58 (28%). Here, only the participants with the principal diagnosis of ID were considered. Of those with ID, 49 (81.7%) had mild ID. There were 11.6% of students with SLD. Among this, 18 (75%) had mixed variety of SLD, four (16.7%) had combined dysgraphia and dyslexia, and two (8.33%) had dyscalculia. Other neurodevelopmental, behavioral, and emotional disorders/problems as the principal diagnosis accounted for 15.5% of the diagnoses \[[Table 2](#T2){ref-type="table"}\]. No particular diagnosis could be ascribed to 21 (10.14%) of students.

When the intellectual level of the sample was assessed, 60 (28.98%) students had ID \[[Table 3](#T3){ref-type="table"}\]. Here, the intellectual level of all participants, whatever their principal or comorbid diagnosis, were taken into consideration vis-a-vis \[[Table 2](#T2){ref-type="table"}\], which represents only the principal diagnosis. Those with average intelligence comprised 29.5%.

###### 

Distribution of intelligence level of participants (*n*=207)

  Intelligence level                   *n* (%)
  ------------------------------------ ------------
  Above average (IQ \>110)             1 (0.48)
  Average (IQ 90-110)                  61 (29.46)
  Below average (IQ 80-89)             22 (10.62)
  Borderline intelligence (IQ 70-79)   63 (30.43)
  ID (IQ \<70)                         60 (28.98)

ID -- Intellectual disability; IQ -- Intelligence quotient

The academic issues of students with average intelligence without SLD are depicted in [Table 4](#T4){ref-type="table"}. ED was the main cause of SB among them (34%).

###### 

Academic issues of students with average intelligence, without specific learning disorder (*n*=38)

  Academic issues of students with average intelligence without SLD   *n* (%)
  ------------------------------------------------------------------- ------------
  PLS                                                                 3 (7.89)
  PLH                                                                 5 (13.15)
  ED                                                                  13 (34.21)
  PLS + PLH                                                           7 (18.42)
  PLS + ED                                                            2 (5.26)
  PLH + ED                                                            2 (5.26)
  None identified                                                     6 (15.79)

PLS -- Poor learning style; PLH -- Poor learning habit; ED -- Environmental deprivation; SLD -- Specific learning disorder

DISCUSSION {#sec1-4}
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This study brings to light a snapshot of the students presenting to psychiatrists in a government teaching hospital with "scholastic backwardness" and thereon referred to clinical psychologist for academic assessment.

In our study, varying degrees of intellectual impairment was the main cause of SB. Slow learner was the single main diagnostic category. In a clinic-based study conducted in Mumbai, the most common diagnosis was specific learning disability (72.76%) followed by borderline intellectual functioning or "slow learner" (8.94%).\[[@ref13]\] However, their sample was different from ours -- 95% were from English medium schools and belonged to the upper middle socioeconomic class. Only 11.6% of our sample had SLD, consistent with other Indian studies. The number of students having "no diagnosis" or a particular cause to account for SB (10%) was almost at par with the number of students with SLD. In a recent school-based study in South India (Andhra Pradesh), the prevalence of SLD was 6.6% in children aged 6--12 years, much less than in our sample.\[[@ref8]\] Combined type of SLD was the most common type among our modest sample though classically dyslexia is the most common type.\[[@ref14]\] There was over-representation of class 10 students in our sample. These students were approaching for assessment for the first time.

The majority of the parents were educated up to high school; fathers were predominantly manual laborers and mothers unemployed \[[Table 1](#T1){ref-type="table"}\]. There was no single first-generation learner in our sample consistent with the high literacy in the state.

A great majority of students were from vernacular medium and state syllabus \[[Table 1](#T1){ref-type="table"}\]. Most of the government schools in the state are in the vernacular medium. Students from CBSE and ICSE syllabus would have approached the private sector for assessment and certification, usually being more economically affordable. Another explanation could be the detrimental trend of expelling poor-performing students from private schools. When students perform poorly, the private schools, majority of which are affiliated to CBSE syllabus shift the students to government state schools, which assures them a pass till class nine due to the "no detention policy" of the government.\[[@ref15]\] This is viewed welcomingly by the parents as well.

Students with SB are identified late and referred late for professional help, depriving opportunities for timely interventions. Teachers were the main source of referral. Few students were identified by parents. It is an interesting observation that not a single student from National Institute of Open Schooling had availed our services during the study. This reflects on poor awareness among parents and teachers about alternate modes of education. It is of concern, that from the upper primary level, during which the opportunity to identify is maximum and providing services has better potential of benefit to the child, the attendance was a dismal 12%!

The "no detention policy" of government, till class nine, fails to an extent in identifying poor performers, and therefore, puts these students at a great disadvantage because valuable time at the most crucial learning and training period are lost. This coupled with benefits to SLD and ID students for class 10 examinations are indirectly promoting late identification and late referral by teachers, again losing out on opportunities for the early identification and interventions. The accommodations given to students with SLD and ID such as extra time and provision of scribes and interpreters do help these students considerably. There is also a flip side to this. The provisions are misused to a great extent. The scribes writing the examinations instead of the students and students with ID passing with higher marks than the usual students is not an uncommon scenario in the state. The schools in their quest for acquiring centum pass also support the inappropriate ways in which the services of scribes/interpreters are used. Parents are also desperate to see their wards as matriculates in a state with high-literacy rate. In the backdrop of such a situation, the intentions of students, from class 9 and 10, referred mainly by their teachers, make us skeptical. Was procuring concession certificate an important reason for referral by teachers and parents? Alternatively, are students with genuine SLD, with academic performance above the threshold of passing the examination, not getting their due benefits? With the rising awareness of SLD, among the ambitious parents and school authorities, there is a trend of misusing SLD certificates.\[[@ref16]\] It is worth noting that the parents of the students brought for assessments though from a rural area and mainly manual laborers, the majority were educated up to high school and none were illiterate. In a state like Kerala with high-literacy rate, the pressure of passing SSLC by hook or by crook tends to be more. Therefore, a high degree of diligence and prudence needs to be exercised in evaluating such students to avoid the errors of omission and commission. In this context, it is worth noting that, psychiatrists who were actively involved in evaluating and certifying SLD have been excluded from the expert panel of SLD assessment, as per the 2018 Gazette of India notification on the guidelines for the assessment of disabilities.\[[@ref17]\]

With the inclusion of SLD as a benchmark disability as per RPWD act\[[@ref18]\] and the ensuing long-term benefits, the already existing murky scenario would become all the more difficult because there could be a high demand for inappropriate certification. This can lead to alarming consequences.

Limitations {#sec2-1}
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This study being a record based one, has its limitations. Response to intervention model (RTI) was not adopted. The approach of studying the single most important cause of SB, rather than all the possible contributing causes in a child was a limitation. Although a multiaxial approach would have been superior, we adopted a pragmatic approach to the diagnosis. However, for those who followed up regularly, services as usual, addressing the multidimensional causes were provided. Lacking standardized tools in the vernacular language, we had to choose a mixed approach for assessment. We had not included in the study, students presenting primarily with indirect presentations such as depression and anxiety.

This should be interpreted as a preliminary study paving the path for well-designed multicentric studies from Kerala, with background and demands quite different from the rest of the country.

CONCLUSION {#sec1-5}
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In students who were assessed for SB in a government teaching hospital, it was found that varying degrees of intellectual impairment was the main cause of SB. "Slow learners" were the single major diagnostic category. Students with SLD constituted 11.6%. Almost the same number of students had "no diagnosis"/cause to account for SB.

Most of the referrals were by teachers when the students reach high school, especially class 10 for the first ever evaluation, possibly to avail the benefits of certification to pass examinations. Late identification and referral of students with SB deprive them of the opportunity to seek timely and appropriate interventions.

Recommendations {#sec2-2}
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Routine schemes for early identification of SB, beginning from the primary school level, prompt referral, and multidisciplinary interventions are the need of the hour. Adopting RTI model for assessment of SLD would lend more credibility to the assessment and certification process.

Defocussing from pure academics and emphasizing on functional and flexible academics, vocational and arts courses with suitable assessments and certifications for the same may to a great extent reduce the undue demand for certification to avail concession for examination.

Designing curriculum and assessment commensurate with the differing intellectual capacities of students should also be considered rather than adopting a policy of "one syllabus and one exam fits all."

Financial support and sponsorship {#sec2-3}
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Nil.

Conflicts of interest {#sec2-4}
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There are no conflicts of interest.
