Not seeing the writing on wall

Dr Jyoti Kapoor

Anya (name changed) was referred to psychiatrist by her paediatrician. The seven-year-old little girl had been complaining of a stomach ache for six months and had stopped going to school for the past three months. Her paediatrician had not been able to find any physical cause for her ache.

Her parents had sought medical help after her total refusal to go to school due to her deteriorating health and her extreme temper tantrums. She often complained of nausea and stomach pain which escalated when she was asked to study. Parents appeared agitated on being asked to seek psychiatric consultation just because her doctors were unable to diagnose the cause of her health problems.

Her birth and developmental milestones had been normal other than a little delay in speech. She had no significant problems in play school and had enjoyed her early kindergarten. She loved listening to stories and watching cartoons like ordinary children. However, for the past two years, her parents had noticed a decline in her academic progress. She avoided studies and enjoyed playing and colouring and her parents often got upset, losing patience and shouting at the child. Her teachers also complained about her lack of attention in class and her avoidance to copy class work from the class board. She was making spelling mistakes and had poor handwriting, often appearing clumsy and ill motivated in classroom. She was being identified as lazy and careless and her emotional excesses were being disliked and condemned during parent-teacher meetings. Suddenly, she started reporting severe abdominal pain and inability to sit in class room for prolonged periods. That is when her parents sought medical advice.

Her mental examination revealed extreme anxiety and some amount of defiance but no intellectual sub-normality. Inspection of her reading skills and handwriting brought out a clearer understanding of her problem. She had dyslexia. Her reading was slow and showed lack of phonological understanding. She was mixing her alphabets — d’s were mixed with b’s, spellings were mostly incorrect and sentences lacked proper sequencing. Anya’s stomach ache had ‘originated’ because of her inability to read or write properly because of dyslexia.

It is a learning disability associated with immature development of the language areas in the brain associated with visual and acoustic processing of symbols that form language. Often referred to as a reading disorder, an individual with dyslexia is unable to process information associated with symbols and sequencing used in language and therefore he/she is unable to read sequence and write language in proper syntax. The key point is that this condition occurs in the absence of any intellectual disability or mental retardation.

The condition manifests itself in academic setting as the child is expected to learn reading. Due to the inability to express their difficulties, many young kids are unable to perform adequately and start avoiding reading and writing tasks. This makes them unfair targets for reprimands and ridicule by teachers and peers, and even family members, causing emotional issues. 

Symptoms 

Young children cannot verbally express their distress. This can cause behavioural disturbance like anxious avoidance of situations that can make them get unpleasant reactions; agitation on being forced to read/write or be part of activities that include these activities; anger and temper tantrums due to stress and negative comments for being slow. Somatic symptoms like stomach ache, loss of appetite, vomiting, bed wetting, breathlessness etc. are a manifestation of anxiety in children.

Difficulty in diagnosis 

Unfortunately, lack of awareness and a denial to recognise anything biologically wrong with the child makes most parents confused and even angry. Most parents avoid visiting psychologists or psychiatrists because of fear of stigma that their child will be labelled, mentally retarded. They sometimes get defensive or even agitated if approached by school teachers for psychological examination of child’s learning difficulties. As in Anya’s case, only an un-explainable physical symptom may push them to seek medical help. 

Difficulties in diagnosis also occur because as a rule, most people and even doctors always try to find a physical cause for physical symptoms initially. Additional physical consequences like bowel movement disturbances, weight loss, nutritional deficiencies, weakness etc. also further complicate the picture.

The psychological impact of such condition is extremely detrimental to a healthy personality development. Children struggle with self esteem issues and may develop un-explained physical symptoms, spending months and even years undergoing diagnostic procedures and treatments to define a specific cause for their physical problems. And it results in distraction from the primary problem. The subconscious accepts physical illness as a better alternative to the real issue and unless explored, the psychological interventions are neither sought nor easily accepted.

Solution 

The solution lies in training the teachers to recognise the tell-tale signs of reading deficiencies as well as spreading awareness among people of its existence and relevance. An educative approach is necessary to make the condition accepted as a real problem and not just an emotional one. A simple screening process can be employed at kindergarten level to understand individual child’s linguistic skills.  Vulnerable children can be then observed for further signs of dyslexia. An early remedial measure is highly effective in aligning child’s reading and writing skills to the norm and preventing unnecessary emotional trauma. 

Our education process needs to be more individualistic as well as holistic especially when a problem is recognised. Identifying subtle neuro-developmental disorders like learning disorders, ADHD and autistic disorders among others at an early stage helps in early intervention and prevents significant emotional and functional consequences associated with such problems.

— The writer is senior consultant, psychiatry and psychotherapy, Paras Hospitals, Gurgaon