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ORIGINAL ARTICLE
Year : 2018  |  Volume : 62  |  Issue : 1  |  Page : 39-46  

Medicosocial characteristics as predictors of school achievements in students with intellectual and developmental disabilities: A follow-up study in ujjain and shajapur districts of Madhya Pradesh, India


1 Associate Professor, Department of Community Medicine, Sri Aurobindo Institute of Medical Sciences, Indore, India
2 Professor, Scientist E - Epidemiology Section, ICMR-National Institute for Research in Environmental Health, (ICMR-NIREH), Bhopal, Madhya Pradesh, India

Date of Web Publication6-Mar-2018

Correspondence Address:
Dr. Harshal Gupta
Department of Community Medicine, Sri Aurobindo Institute of Medical Sciences, Indore Madhya Pradesh
India
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Source of Support: None, Conflict of Interest: None


DOI: 10.4103/ijph.IJPH_366_16

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   Abstract 


Background: For a long time, there have been arguments about which factors influence the skill development of students with intellectual disability in rehabilitation centers. Objective: The present follow-up study was thus planned to analyze the effect of the demographic variables related to disabled child, his/her parents and the family; their schooling pattern and types of study settings and the associated comorbidities on improvement in the performance score of students attending these study settings in one academic year. Methods: The study was conducted among children (n = 204) with intellectual disability receiving rehabilitation services in centers run by a nongovernmental organization in two districts of Central India. Results: Application of regression analysis concluded that among various hypothesized factors higher birth order, more time spent by parents for child’s development at home, high performing classes, absence of epilepsy, psychiatric comorbidities, and associated physically challenged were significantly associated with improvement in overall mean performance score. Conclusions: The study delineates the need to motivate parents, so that they can involve themselves to develop their child’s full potential. Identification of associated comorbidities is recommended and parents need to be appraised accordingly.

Keywords: Intellectual disability, mental retardation, rehabilitation, special education


How to cite this article:
Gupta H, Sabde Y. Medicosocial characteristics as predictors of school achievements in students with intellectual and developmental disabilities: A follow-up study in ujjain and shajapur districts of Madhya Pradesh, India. Indian J Public Health 2018;62:39-46

How to cite this URL:
Gupta H, Sabde Y. Medicosocial characteristics as predictors of school achievements in students with intellectual and developmental disabilities: A follow-up study in ujjain and shajapur districts of Madhya Pradesh, India. Indian J Public Health [serial online] 2018 [cited 2019 Dec 6];62:39-46. Available from: http://www.ijph.in/text.asp?2018/62/1/39/226621




   Introduction Top


Intellectual development disorder (IDD)[1] or mental retardation (MR)[2] is a generalized neurodevelopmental disorder characterized by significantly impaired intellectual and adaptive functioning and an IQ under 70. IDD has prevalence of 1%–3% in India[3] as well as globally.[4] With growing awareness in the community with respect to characteristics, needs and individual potential of people with intellectual and developmental disabilities (PwIDD), the goal now for them is to stay in the family and take part in community life.[5] However, education and training of these students have been a challenge.[6]

At present, we are passing through a phase of rehabilitation where in efforts are being made to spread services and training programs to raise awareness related to mainstreaming and provision of equal opportunities for PwIDD.[7] Latest philosophy in prevocational training is inclusion in education, defined as “the commitment to educate each child to maximum extent appropriate for the school and classroom he would otherwise attend”.[8] While a large number of developed countries now have policies promoting “inclusive education,” a number of developing countries continue to provide educational services to students with disabilities in “segregated” schools.[9] Typically, special school setting means that students with disabilities are served primarily in segregated education settings under special classroom teacher. In integrated education model whenever possible, students with disabilities attend a regular school.[9] Mainstreaming of special children in normal schools is not largely accepted due to societal ignorance, taboos, parental denial, and lack of specialists.[4]

However, expecting a complete solution from educational efforts and integration dynamics is optimistically oversimplifying the biomedical perspectives for underlying etiologies of a variety of spectra of conditions that result in IDD. PwIDD are more likely to have other associated physical and mental health problems.[7] Naturally, before expecting educational skills to be followed by societal integration, underlying medical condition needs particular attention to avoid health disparities that will cause social disparities in later adult life.[7] Apart from these, medical perspectives some researchers attribute student’s skills to the type of rehabilitation center[9],[10] they are enrolled in; others indicate student’s demographics[7],[11],[12],[13] as important. Some researchers mentioned parental involvement[10],[14],[15] in special education can help in skill development while others suggest family and socioeconomic characteristics[12],[16] as important. For a long time, there have been arguments about which factors influence student’s performance in such settings. Therefore, this study was planned to analyze the demographic variables related to disabled child, their parents and family, their schooling pattern, and types of rehabilitation center and associated comorbidities. In addition, development of study participants in terms of improvement in performance score in one academic year was evaluated. Thus, the specific objective of this study was to analyze these medicosocial factors and their effect on improvement in performance score of students attending a special school and its integrated training centers (ITCs) in two districts of Central India in one academic year.


   Materials and Methods Top


The study design was a follow-up study over one academic year (July 2011–April 2012). The study was performed at two purposively selected districts, i.e., Ujjain and Shajapur districts of Madhya Pradesh, India. At the time of study, there were total five prevocational rehabilitation centers for PwID in selected districts (three in Ujjain and two in Shajapur). Of these five centers, four were run by non-government organization (NGO) “Madhya Pradesh Vikalang Sahayata Samiti”, that include Manovikas special school and its all three outreach settings i.e. integrated training centers (ITCs). The study was conducted at the four centers run by NGO Madhya Pradesh Vikalang Sahayata Samiti. Two Study centers, i.e., Manovikas special school, Ujjain and Prateksha ITC, Nagda, are located in Ujjain district and two centers, i.e., Udaan, Agar, and Navjeevan, Shujalpur ITCs are located in Shajapur district of Madhya Pradesh. All the students studying at selected centers were included in the study; however, students with profound MR, whose parents did not consent and who could not complete one academic year after start of study were excluded from the study. A total of 204 (92.3%) students out of 221 enrolled fulfilled the inclusion criteria from all study settings. This includes 25 students from Manovikas school on whom pilot study was conducted initially.

Data collection

Situational analysis of all study centers was conducted to assess the infrastructure of each school, facilities available, and teachers training component. To start with, group meetings of the class teachers were arranged in both types of study setting to apprise them the purpose of the study. Meetings were held with parents or caretaker (for students staying with foster parents) during periodic teacher-parent meetings within the school premises to collect sociodemographic details using a pilot tested, semi-structured questionnaire. Medical problems of PwIDD and associated physically challenged, namely, physical disabilities due to cerebral palsy, deaf/dump, or blind were interviewed from parents and school medical records of students were verified. Help of school appointed psychologist was taken.

Assessment of rehabilitative services

Study of student’s performance scores record files in schools was done. The study centers use functional assessment checklists developed by National Institute for Mentally Handicapped, Secunderabad (NIMHS) on regular basis for the assessment of performance of these children. To do scoring using these checklists, the special educators get regular training. Entry level scores were recorded during start of academic year (July 2011). Repeat assessment of performance score was done after the completion of one academic year (April 2012). Most of the items listed in checklists are activity based. Students are grouped into different levels (classes) such as preprimary, primary, secondary, and prevocational based on their ability and chronological age and each group has separate checklist. Reliability and validity of the checklist are established by field testing by NIMHS. Details of checklists are available from www.nimhindia.gov.in/facp.pdf.[17]

Ethical considerations

Protocol of the study was approved by Ethics Committee of the institute. Information sheet was undersigned by NGO Head. Written informed consent was taken from parents. Analysis was done using SPSS 20 (IBM SPSS, Bangalore).


   Results Top


Situation analysis of schools

The study settings had almost similar infrastructure and facilities. Teachers from all centers receive training yearly to use checklists during various sessions conducted by NGO in Manovikas school. The difference in two types of study settings was basically in organization of classes. In special school, PwIDs were segregated totally in a separate school setting. However, in ITCs, teachers work in close collaboration with physical training, music, and art teachers who will have special children along with normal children during their classes, promoting physical and social integration, and not academic integration.

Distribution of improvement in mean performance scores according to various medicosocial factors

As sample size (n = 204) which included all the PwID enrolled in the study settings, data were assumed to be normally distributed. [Table 1] shows the distribution of improvement in mean scores according to background characteristics of study participants. Assuming proportion of females to be 50% and studies showing prevalence of mental disorders equal in both males and females,[18] the Z score value is −5.46 (P < 0.00). Assuming proportion of rural population to be 70%, the Z score value is −19.51 (P < 0.00).
Table 1: Distribution of overall improvement in mean performance scores over one academic year according to student’s characteristics (n=204)

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Distribution of mean scores according to parent’s characteristics of study participants are presented in [Table 2]. [Table 3] illustrates the distribution of scores according to factors associated with schooling. Results indicate that overall improvement was more in special school setting (14.30) than in ITC (13.97), the difference was although not statistically significant. [Table 4] illustrates the distribution of scores according to the factors associated with disability.
Table 2: Distribution of overall improvement in mean performance scores over one academic year according to parent’s characteristics (n=204)

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Table 3: Distribution of overall improvement in mean performance scores over one academic year according to factors associated with schooling (n=204)

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Table 4: Distribution of overall improvement in mean performance scores over one academic year according to factors associated with disability (n=204)

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Further analysis was performed for variables where P value for ANOVA is <0.05 using post hoc Tukey’s test. Results indicate statistically significant difference in mean scores between parents giving no time to their children at home then the parents giving 1–2 h. Further statistically significant differences were found between mean scores of poor and neutral/good performing classes and not between neutral and good performing classes. Further post hoc analysis reveals statistically significant differences between mean scores of mild and severe degree of retardation.

Results related to performance score over one academic year of study participants

The overall mean performance score improvement in all the study settings was 14.15 (12.74–15.56) over one academic year. Analysis by paired t-test revealed significant improvement in overall mean performance score in PwID (P = 0.00).

Application of multiple linear regression analysis to study the actual effect of different factors on the performance score

The three steps of regression analysis was conducted.

Multivariate linear regression (MLR) analysis of various medicosocial factors influencing the performance score of students was performed. Various hypothesized factors were not found to be significant at α = 0.05 when adjusted for other factors. Hence, to include the marginally significant hypothesized factors which could influence performance score outcome in the final reduced model, we identified the factors having P < 0.25 from full model MLR. In second step of analysis, each of mediating variables with P < 0.25 were regressed again. In third step of analysis, we identified the factors having P < 0.05 and each of mediating variables with P < 0.05 were regressed again and the final results of MLR are shown in [Table 5].
Table 5: Final model of multivariate linear regression analysis of various statistically significant factors on performance score of students over one academic year

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Regression coefficient for mediating variables is 22.6% with P = 0.00. Constant (a) for our Final model is 10.49% with significant P value which means that even without contribution of any factor, a student would improve his skills by 10.49% in 1 year.

The suggested final equation is:

Mean performance improvement score (percent) = 10.49 + 1.69 × Birth order + 2.70 × Time spent by parents for child’s development at home + 3.33 × Class − 2.89 × Epilepsy − 3.69 × Psychiatric comorbidities − 4.24 × Associated handicap.


   Discussion Top


Situation analysis of schools and background characteristics

A total of 204 students were studied with mean age 13.02 (range 4–34 years). Equal representation of females was expected based on the available literature about gender-wise distribution of mental disorders.[18] However, our study results indicated the underrepresentation of females in the schools. This is in line with findings of Ricci and Hodapp[19] which revealed that the effect of gender favoring boys occurred when fathers played with and taught boys more than girls with IDD. Majority of the study participants were from urban areas, and results indicate the underutilization of services by rural population. This might be because the study settings were located in urban areas. These findings necessitate opening of study centers in rural areas. Majority of the study participants belonged to medium socioeconomic status (SES). Majority of the mothers of study participants were educated and were homemakers. This might be because more of educated parents have tendency to send their children to schools. Similar findings were reported by Figen et al. that parent’s education has a positive impact on skills acquisition.[7]

Associated physically challenged (61.3%) was found to be the most common associated comorbidity. The number of associated disorders appeared to increase with increasing the severity of intellectual disability. These results are in conformity with results of Reid and Ballinger[20] and Ahmad et al.[3] who, studied that behavior symptoms and psychiatric disorders were more in severe MR.

Distribution of overall improvement in mean scores according to regression analysis of various factors influencing performance of students

The three-step regression analysis revealed that among all factors birth order, time spent by parents for child’s development at home, class, epilepsy, psychiatric comorbidities, and associated physically challenged were found to be significantly associated with improvement in performance in one academic year.

Results of regression analysis revealed that there was no significant relation between age and performance achievement of students. Similarly, Figen et al. did not find impact of age on skill acquisition.[7] Female student had better improvement then male student though the finding was not statistically significant. This might be because children of both sex are equally affected by disabilities and thus might not be the determining factor in the acquisition of skills. These results are in conformity with Nourani[10] and Figen et al.,[7] who reported that gender differences were not significant in the development of performance skills of mentally challenged.

Student with higher birthorder had better performance then student with lower birthorder. The result is in line with Hanneman and Blacher, who indicated that mothers promoted more serious consideration of placement when had larger number of siblings.[13] The effect of family type, size, and religion on acquisition of skills was also not found significant. This may be explained by the fact that major responsibility of child with ID is of the parents directly irrespective of different types and size of family. The findings are at par with Neely-Barnes et al., who also reported that family involvement was not affected by caste, religion, type of family, and number of members in the family.[12]

Our finding also depicts nonsignificant relation of family income and acquisition of skills in one academic year. Similar result was reported by Figen et al.,[7] who observed that average family income did not contribute in the learning of self-help skills. The above findings might be due to the fact that better environment provided by parents in training of the mentally challenged children was irrespective of their financial conditions. The findings are in congruent with Trivette et al., who found similar results.[16] Contradictorily, Neely-Barnes et al. reported that higher income families were more involved than lower income families.[12] Results also depict that performance score of students was not significantly influenced by SES of family. It may be because parents from all the socioeconomic background provides equal care and support during training of their children. The present findings are substantiated with studies of Bailey, who also did not find SES as predictor for the involvement of parents.[11]

About the time shared by parents with children at home for their development indicated that better performance of student was associated with more parental involvement than less or no parental involvement. The performance of students was associated with time shared by parents with children at home for their development irrespective of caretaker’s education or working status. The findings are supported by Verdonschot et al., who reported that parental involvement has positive effect on community participation of PwID.[21] Similarly, Alvey and Aeschleman[22] and McIntyre[23] and Figen et al.[7] found that training of children from their parents enhance the skills. There was no significant relation between factors associated with schooling, namely, type of study setting to which student is enrolled with his improvement in performance score in one academic year. This might be because the training of student is important which can be in either segregated or integrated setting. Since results revealed that ITC is at par with special school in providing skills to PwIDD, it is cost-effective to open more ITC as regular school premises can be utilized and special setup is not necessary. Contradictorily, Bouck[8] and Sharma and Deppeler[9] reveals that integrated settings provides good role models. The improvement in performance score of students over one academic year was also not significantly influenced by the duration of schooling. This might be because the study settings had individualized education plan (IEP)[17] for every student according to his skills assessed during start of that academic year based on which appropriate checklist was used. Although positive correlation (r = 0.507) was found between baseline performance score taken at the start of study and duration of schooling. This explains the importance of rehabilitation through school services in the development of skills in individuals with intellectual disabilities. Results also depicts that the class to which students were studying in during the study showed a significant association with scores improvement. This result was obvious as the distribution of students in respective classes was based on their performance skills during admission in respective schools.

IQ level is prerequisite to children to acquire the skills (as per DSM-IV-TR) still there was no significant association between degree of MR and improvement in scores. This can be because the checklist used to assess the performance were IEP based on their ability and chronological age. Many researchers, namely, Schatz and Hamdan-Allen[24] and Bruschini et al.[25] reported that IQ was positively related to the adaptive behavior. However, Graham found no difference between the groups.[26] Students with epilepsy, psychiatric comorbidities, and associated physically challenged had lower improvement in performance score then in students without them. The findings are in congruent with Bölte[27] and Wilkins and Matson,[28] who found social skills deficits more in mentally retardation with associated disabilities than only MR. Contradictorily, Graham reported that associated disability did not contribute to skill development.[26] The interactional effect of epilepsy on the performance of student was found significant. This could be because students without epilepsy were regular in attending schools (as told by teachers) so had better scores. Although interactional effect of hyperkinesis and emotional behavioral disturbances were not found significantly associated with improvement in performance score. It might be because these conditions get difficult to be diagnosed in severe cases of MR with low IQ, so are generally associated with milder forms of MR and so with better scores. However, psychiatric comorbidities were found significantly associated with improvement in score. This could be because associated psychiatric comorbidities marks the difficulty in acquiring skills in PwID. With respect to results on associated physically challenged, it was noted that significant association was found with improvement in score. This could be because these associations further worsen the condition of PwID and has deteriorating effect on skills acquisition.


   Conclusions Top


Significant improvement was observed in the performance scores of children with intellectual disability in all study settings. The overall improvement of students in ITCs was at par with special school. Higher birth order, more time spent by parents for child’s development at home, high performing classes, absence of epilepsy and psychiatric comorbidities, and associated handicap were significantly associated with improvement in overall mean performance score.

Recommendations

The students with intellectual disability should be sent to rehabilitation centers to ensure their development. It is recommended to open more ITCs as they were at par to special school in skill development of PwIDD and are also cost-effective. There is need to motivate parents, so that they can involve themselves and spend more time with their disabled children to develop their full potential. Before expecting educational skills to be followed by societal integration, underlying medical condition needs particular attention. Hence, identification of associated disabilities is recommended and parents need to be appraised accordingly.

Limitations

Being a center-based study, it suffered limitations of underrepresentation of females and unequal proportion of locality.

Acknowledgment

Authors deeply acknowledge the study participants and school authorities for their cooperation. The authors are grateful to referees for their valuable suggestions regarding the improvement of the research paper.

Financial support and sponsorship

Nil.

Conflicts of interest

There are no conflicts of interest.



 
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    Tables

  [Table 1], [Table 2], [Table 3], [Table 4], [Table 5]



 

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