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Indian Journal of Pediatrics, Volume 72—November, 2005 961
Correspondence and Reprint requests : Dr. Sunil Karande, Flat 24,
Joothica, 5th Floor, Opposite Grant Road Post Office, 22A, Naushir
Bharucha Road, Mumbai-400 007, India. Fax No. : 91-22-2407 6100
Symposium on Developmental and Behavioral Disorders - II
Education is one of the most important aspects of human
resource development. Every child should have the
opportunity to achieve his or her academic potential. It is
generally noticed that at least 20% of children in a
classroom get poor marks - they are “scholastically
backward”. Poor school performance should be seen as a
“symptom” reflecting a larger underlying problem in
children. This symptom not only results in the child
having a low self-esteem, but also can cause significant
stress to the parents. It is essential that this symptom be
scientifically analyzed to discover its underlying cause(s)
and find a remedy. This article reviews the causes for
children to have poor school performance and describes
its management.
Causes of Poor School Performance
There are many reasons for children to underperform at
school, such as, medical problems, below average
intelligence, specific learning disability, attention deficit
hyperactivity disorder, emotional problems, a poor socio-
cultural home environment, psychiatric disorders, or even
environmental causes.
(1) Medical Problems
These conditions have been reported to have an
Poor School Performance
Sunil Karande and Madhuri Kulkarni
Learning Disability Clinic, Division of Pediatric Neurology, Department of Pediatrics, Lokmanya Tilak Municipal
Medical College and General Hospital, Sion, Mumbai, India
Abstract. Education is one of the most important aspects of human resource development. Poor school performance not only
results in the child having a low self-esteem, but also causes significant stress to the parents. There are many reasons for
children to under perform at school, such as, medical problems, below average intelligence, specific learning disability, attention
deficit hyperactivity disorder, emotional problems, poor socio-cultural home environment, psychiatric disorders and even
environmental causes. The information provided by the parents, classroom teacher and school counselor about the child’s
academic difficulties guides the pediatrician to form an initial diagnosis. However, a multidisciplinary evaluation by an
ophthalmologist, otolaryngologist, counselor, clinical psychologist, special educator, and child psychiatrist is usually necessary
before making the final diagnosis. It is important to find the reason(s) for a child’s poor school performance and come up with
a treatment plan early so that the child can perform up to full potential. [Indian J Pediatr 2005; 72 (11) : 961-967]
E-mail : karandesunil@yahoo.com
Key words : Dyslexia; Intelligence; Learning disorders; Risk factors; Socioeconomic factors; Student dropouts
independent effect resulting in poor school performance.
(a) Preterm birth and low birth weight (LBW): Up to 33%
of children born between 32 and 35 weeks gestation and
up to 25% of LBW babies (< 2000 g) are at risk for school
difficulties into late childhood, even when not
neurologically impaired.1,2 Arithmetic, vocabulary,
concentration, non-verbal intelligence, and attention
problems are significant mediators of the effect of LBW on
the school performance score.2,3 Children born preterm,
small for gestational age or with very low birth weight (<
1500 g), tend to have the poorest cognitive abilities.3,4
(b) Malnutrition and nutritional deficiencies:
Malnutrition in early childhood is associated with poor
cognition in later years and this is independent of
psychosocial adversity.5 Chronic iron deficiency anemia,
zinc deficiency and inadequate intake of vitamins A, B1,
B2, B6, D3, and E and niacinamide adversely affect long-
term cognitive development.6-8
(c) Worm infestations: Infestation with roundworm,
hookworm and whipworm often affects malnourished
children’s school performance because it can stunt
growth, decrease physical activity, and cause poor mental
development.9, 10, 11
(d) Hearing impairment: Children with otitis media with
effusion and associated conductive loss during the first 4
years of life have been reported to score lower in math
and expressive language between kindergarten and
second grade.12 Mild sensorineural hearing loss affects
about 5 % of the school-aged population and these
children experience difficulty on a series of educational
and functional test measures.13 Low birth weight and
pyogenic meningitis are known risk factors for
sensorineural deafness.14-16
Sunil Karande and Madhuri Kulkarni
962 Indian Journal of Pediatrics, Volume 72—November, 2005
(e) Visual impairment: Amblyopia is present in 1.6-3.6%
of preschool children and if left uncorrected may harm
school performance.17, 18 Reduced vision because of
uncorrected refractive error is a major public health
problem in children in India.19 Murthy et al have reported
an age-related shift in refractive error from hyperopia in
young children (15.6% in 5-year-olds) toward myopia in
older children (10.8% in 15-year-olds). Overall, hyperopia
is present in 7.7% of children and myopia in 7.4%.18
The risk of refractive errors is higher in preterm infants
than in infants born at term.20, 21
(f) Asthma and allergic rhinitis: Children with poorly
controlled asthma have increased school absenteeism.22
Children with moderate to severe “chronic asthma” may
perform poorly due to the stress associated with a chronic
illness.23 Even short-term administration of theophylline
to asymptomatic asthmatic children can adversely affect
school performance.24 Both uncontrolled symptoms of
allergic rhinitis, as well as adverse effects from
antihistamines, can diminish cognitive function and
learning.25
(g) Epilepsy: Children with new onset idiopathic epilepsy
are inordinately vulnerable when processing memory
tasks.26 Maladaptive reactions of parents and children to
the onset of epilepsy and not reaching 6-months of
seizure remission also contribute to poor school
performance.26 In a subset of epileptic children, anti-
epileptic drugs (AEDs) can themselves affect cognition
adversely. Although all AEDs have the potential for
adverse effects on cognition, phenobarbitone and
topiramate have the highest potential for causing
cognitive dysfunction.27
(h) Cerebral Palsy: Children with cerebral palsy have
functional activity limitations which can significantly
impair their learning.28 Additional co-morbidity (visual
disability, epilepsy) further complicates their problem.28
(i) Leukemia and lymphoma: Cranial irradiation is the
major cause of learning problems in children treated for
leukemia and lymphoma, especially those who have been
irradiated when under 6 years of age.29, 30
(j) Sickle cell anemia: Children with silent cerebral
infarcts show high rates of poor educational attainment.31
(k) Thallasemia major: Poor school performance can
occur due to frequent absenteeism due to the need to
receive monthly packed cell transfusions.32
(l) Hemophilia: Increased school absenteeism and
hemophilia-related limitations in physical functioning
among children with greater frequency of bleeding
episodes result in lower academic scores.33
(m) Type I Diabetes mellitus: Children with
hospitalizations for hyperglycemia are at risk for
academic underachievement due to increased school
absenteeism. Also, children with hypoglycemic
hospitalizations need careful monitoring to ensure that
episodes of hypoglycemia associated with seizures are
not adversely affecting learning.34
(n) Congenital hypothyroidism (CH): School attainments
of early treated CH children are within the normal range
in most affected cases.35, 36 Low IQ scores and poor
language performances at the age of 5 yrs are associated
with subsequent school learning disorders.35 Recurrent
episodes of insufficiently suppressed TSH levels (> or =
15 mUi/L at least four times during follow-up from the
age of 6 months onwards) are associated with school
delay.36
(o) Habitual snoring: Sleep-disordered breathing with
habitual snoring is associated with hyperactive,
inattentive behavior and poor academic performance in
primary school children.37, 38 This underachievement may
continue even after the habitual snoring ceases post
tonsillo-adenoidectomy.38
(2) Below Average Intelligence
It is well known that intelligence (measured as the
intelligence quotient or IQ) is one of the important
prognostic variables in the academic outcome of children.
Children with borderline intelligence or “slow learners”
(IQ 71 to 84), or mental retardation (IQ≤70), irrespective of
the etiology (past history of prematurity, neonatal
TORCH infections, meningitis, encephalitis, head injury;
Down syndrome, Fragile X syndrome, Turner syndrome,
Klinefelter syndrome, etc.) present with poor school
performance or school failure.39, 40 Children born and
brought up in iodine-deficient environment have
significant impairment in language, memory, conceptual
thinking, numerical reasoning and motor skills.41 Children
with below average intelligence usually have history of
developmental delay.39
(3) Neurobehavioral Disorders
(a) Specific learning disability (SpLD): 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,
normal intelligence, proper motivation and adequate
socio-cultural opportunity.42, 43 SpLD is presumed to be
due to central nervous system dysfunction.44 A history of
language delay, or of not attending to the sounds of
words (trouble playing rhyming games with words, or
confusing words that sound alike), along with a family
history, are important red flags for dyslexia.43 Substantial
evidence has established that the children with dyslexia
have deficits in phonologic awareness.44 The functional
unit of the phonologic module is the “phoneme”, defined
as the smallest discernible segment of speech; for
example, the word “bat” consists of three phonemes: /b/
/ae/ /t/ (buh, aah, tuh). Children with dyslexia have
difficulty developing an awareness that words, both
written and spoken, can be broken down into smaller
units of sound and that, in fact, the letters constituting the
Poor School Performance
Indian Journal of Pediatrics, Volume 72—November, 2005 963
printed word represent the sounds heard in the spoken
word.44 Dyslexia is genetically inherited and boys
generally outnumber girls in the ratio of three to one.43
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 are the
hallmarks of this life-long condition.42, 43
Dyslexia affects 80% of all those identified as learning-
disabled and its incidence in school children in USA
ranges between 5.3- 11.8%.43, 45 Information on SpLD in
Indian children is scanty. The incidence of dyslexia in
primary school children in India has been reported to be
2-18%, of dysgraphia 14%, and of dyscalculia 5.5%.46-48
(b) Attention deficit hyperactivity disorder (ADHD):
ADHD affects 8-12% of children worldwide and results in
inattention, impulsivity and hyperactivity.49 Children
with ADHD are at risk for poor school performance.49 Up
to 20-25% of children with ADHD have SpLD and vice
versa.43, 49
(c) Autism: Even non-retarded autistic children face a lot
of problems in school as their core features (impairment of
reciprocal social interactions, impaired communication
skills and restricted range of interests or repetitive
behaviors) impair learning.50, 51 These core features do not
change qualitatively. Also, they often demonstrate
distress and opposition when exposed to requests to
complete academic tasks.50, 51
(d) Tourette syndrome (TS): Children with TS are at a
higher risk for academic failure.52 In the majority of TS
patients, the disorder starts with ADHD and 2.4 years
later, develops motor and vocal tics. Specific cognitive
deficits, presence of co-morbid conditions, notably ADHD
and oppositional conduct disorder significantly increase
the likelihood that an individual with TS will also have
learning problems.52
(4) Emotional Problems
Conditions which cause emotional problems in children
viz. chronic neglect, sexual abuse, parents getting
divorced or losing a sibling might cause long term distress
resulting in academic underachievement.53-56 Children can
face severe emotional upheavals during the treatment of
chronic health impairments such as asthma, cancer,
cerebral palsy, congenital heart disease, diabetes mellitus,
epilepsy, hemophilia, rheumatic diseases, or thallasemia,
resulting in low self-esteem and loss of motivation to
study.23, 26, 32-34, 57-59 Despite average intelligence, absence of
significant family dysfunction and advantaged social
background, a large number of children with isolated
growth-hormone deficiency or with idiopathic short
stature develop low self-image, behavioral problems and
have academic underachievement.60 In recent times, HIV-
infected children have also been reported to exhibit
clinically significant emotional problems.61
(5) Poor Sociocultural Home Environment
It has been recognized that children from poor socio-
economic status families have higher chances of poor
school performance.62-66 Malnutrition due to poverty
coupled with low education and status of parents
adversely affect their cognitive development.64, 65 Such
children also have higher chances of experiencing, right
from their pre-school years, parental attitudes which do
not motivate them to study and an unsatisfactory home
environment which does not encourage learning
(witnessing domestic violence, family stressors, adverse
life events).66, 67
Another feature we regularly observe in our clinic is
that many of these disadvantaged children are studying
in English medium schools as their parents believe that
this would help them progress in life. These children face
the added burden of “language barrier”, namely, they are
not conversant in English as they came from non-English
speaking families, which leads to poor school
performance or even school failure.
(6) Psychiatric Disorders
Poor academic functioning and inconsistent school
attendance are the early signs of emerging or existing
depression or psychosis.68 Clinicians need to inquire not
only about the classic symptoms of depression such as
anhedonia but also about less obvious symptoms such as
unprovoked irritability, unsubstantiated complaints of
lack of love from family members, somatic complaints,
and problems with concentration in school.68 Conduct
disorder and oppositional defiant disorder are other
known psychiatric causes of poor school performance. It
is well known that Wilson disease and subacute sclerosing
pan encephalitis (SSPE) can present as change in the
child’s personality and deteriorating school performance.
(7) Environmental Causes
Children living in noisy environment can exhibit poor
academic performance.69 Too much television-viewing
among children has been linked with inadequate study
patterns.70, 71 Inappropriate television-viewing among
adolescents has been linked to erratic sleep/wake
schedules and poor sleep quality, violent or aggressive
behavior, substance use, sexual activity resulting in
decreased school performance or even school drop-out.70,
71 There is irrefutable evidence that environmental-lead
exposure can lead to mild intellectual impairment,
hyperactivity, shortened concentration span, hearing
impairment, violent/aggressive behavior all resulting in
poor school performance.72
Management of Poor School Performance
(1) Approach to the Diagnosis: It is important to
remember that a child may be having more than one
reason for the poor school performance. Hence the
Sunil Karande and Madhuri Kulkarni
964 Indian Journal of Pediatrics, Volume 72—November, 2005
pediatrician should take a detailed medical and
developmental history and do a thorough physical and
neurological examination to identify any medical,
neurobehavioral, emotional, socio-cultural, psychiatric or
environmental causes for the poor school performance.
Also, the pediatrician should gather information from the
parents, classroom teacher and school counselor which
clearly describe the child’s behavior, social functioning
and the academic difficulties. This information is crucial
for the pediatrician to form an initial diagnosis.
Next, the pediatrician should refer the child to other
specialists before a final diagnosis can be made. For this,
an evaluation by an ophthalmologist, otolaryngologist,
counselor and clinical psychologist is necessary for each
child. Vision and audiometric testing should be done and
correctible visual and hearing problems should be
attended to. The Counselor should take a thorough social
history to find out details of the home and school
environments and to rule out that problem due to stress at
home or school is not primarily responsible for the child’s
academic underachievement. In case the problems are
severe, for example, severe anxiety or depression, it is
necessary that the child be assessed and treated
(psychotherapy, medications) by a child psychiatrist
before the child’s IQ is determined. The clinical
psychologist should perform a standard test, for example,
Wechsler Intelligence Scale for Children (WISC) test or
the Stanford Binet Intelligence Scale for determining the
child’s level of intelligence (IQ) to identify borderline
intellectual functioning and mental retardation.42, 43
However any such test should be adapted to the country’s
population before being used, for example WISC test
[Indian adaptation by MC Bhatt].73
Depending on the history, additional evaluation by a
child psychiatrist and/or a special educator may also be
necessary. It is advisable to consult a child psychiatrist
before a final diagnosis of ADHD, autism or Tourette
syndrome is made. The special educator assesses the
child’s academic achievement by administering a
standard educational test (e.g. Wide Range Achievement
Test, Peabody Individual Achievement Test, Woodcock-
Johnson Tests of Achievement, Schonnel Attainment Test,
or Curriculum Based Test) which assesses the child’s
performance in areas such as reading, spelling, written
language, and mathematics. An academic achievement of
two years below the child’s actual school grade placement
or chronological age is considered diagnostic of SpLD.42, 43
(2) Treatment: This should begin as soon as the
reason(s) is identified. If any specific medical reason has
been identified, the pediatrician should treat it as
effectively as possible. For example, correction of hearing
and/or visual impairment, optimum control of asthma,
prescribing a non-sedating second-generation
antihistamine for allergic rhinitis, rational therapy of
epilepsy to achieve seizure control by using the correct
AED effectively, and achieving long-term euglycemic
control in juvenile diabetics. It is the responsibility of the
pediatrician to ensure that the parents are sufficiently
educated about any chronic medical condition, especially
congenital hypothyroidism or Wilson disease, so that
non-compliance with the treatment does not again lead to
poor school performance.
In general, children, irrespective of their physical,
sensory, or neurobehavioral deficits, must be educated in
regular mainstream schools (“inclusive education”).
Referral to special schools should be made only in
exceptional circumstances for children with severe and
profound impairments. If a child with borderline
intelligence finds it extremely difficult to cope with the
curriculum and speed of teaching in regular mainstream
schools, a change to the curriculum of the National
Institute of Open Schooling (NIOS), an autonomous
organization by the Ministry of Human Resource
Development, Government of India (http://
www.nos.org/) may be needed.74 Children with mental
retardation may also need to avail appropriate special
education. For reasons stated earlier, non-retarded autistic
children may require to attend special schools.
The cornerstone of treatment of SpLD is remedial
education, which should ideally begin early when the
child is in primary school.42, 43 Using specific teaching
strategies and teaching materials, the special educator
formulates an individual education program to reduce,
eliminate or preclude the child’s deficiencies in specific
learning areas such as reading, writing and mathematics
identified during the child’s educational assessment. The
child has to undergo remedial education sessions twice or
thrice weekly for a few years to achieve academic
competence.75 During these sessions the child undergoes
systematic and highly structured training exercises 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).43,
75 The child also requires practice in reading stories, both
to apply newly acquired decoding skills to reading words
in context and to experience reading for meaning.43 The
management of SpLD in the more time-demanding
setting of secondary school is based more on providing
provisions (accommodations) rather than remediation.42,43
These provisions, e.g. exemption from spelling mistakes,
availing extra time for written tests, dropping a second
language and substituting it with work experience,
dropping algebra and geometry and substituting them
with lower grade of mathematics and work experience,
are meant to help the child cope up in a regular
mainstream school. 42, 43 With appropriate remedial
education and provisions, most children with SpLD can
be expected to achieve academic competence and
complete their education in a regular mainstream
school.42, 43 However, some children with SpLD who
continue to experience academic failure in spite of
remediation and provisions may need to change to the
NIOS curriculum.74
Children with ADHD need psychiatric consultation for
Poor School Performance
Indian Journal of Pediatrics, Volume 72—November, 2005 965
counseling, behavior modification, and/or medications,
such as methylphenidate or atomoxetine.49 Medications
have been shown to be effective in significantly reducing
the symptoms of inattention, impulsivity and
hyperactivity resulting in improved school performance.49
Children with ADHD should continue their education in
regular mainstream schools.49 Children with TS need
psychiatric medications for their verbal/motor tics and
co-morbidities. Some children with TS have SpLD which
needs remedial education and provisions.50
Children with emotional problems need counseling
sessions with a child psychologist or a child psychiatrist.
Depending on the severity, at times, appropriate
medications (anxiolytics, antidepressants) may be needed.
Alleviation of hunger, by providing one balanced
meal in school, is one of the mechanisms to improve
academic achievement in undernourished low-income
elementary school children.76 Treatment of iron
deficiency anemia and multivitamin deficiencies, zinc
supplementation and deworming is also beneficial in
malnourished children.6-8,11 Parents of children with
“language barrier” should be counseled to educate their
children in their own language medium schools or to
attend a facility for “language stimulation” if that is
available and affordable.77
Prevention of Poor School Performance
Teachers should be trained to suspect emotional
problems, SpLD, and ADHD so that they are diagnosed
and treated early. Programs aimed at alleviation of
poverty and adult illiteracy, providing good ante-natal
and peri-natal services, well-baby clinics (exclusive
breastfeeding up to 4-6 months, proper weaning,
immunization), universal use of iodized salt, school
feeding programs (midday meal), periodic deworming,
vitamin A supplementation programs, regular vision and
hearing screening camps in schools can help prevent poor
school performance.
Acknowledgement
We thank our Dean, Dr. M.E. Yeolekar, for granting us permission to
publish this article.
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