Anxiety levels in mothers of children with specific learning disabilityS Karande1, N Kumbhare1, M Kulkarni1, N Shah2
1 Department of Pediatrics, Learning Disability Clinic, Lokmanya Tilak Municipal Medical College and General Hospital, Mumbai - 400 022, India
2 Department of Psychiatry, Learning Disability Clinic, Lokmanya Tilak Municipal Medical College and General Hospital, Mumbai - 400 022, India
Correspondence Address: Source of Support: None, Conflict of Interest: None DOI: 10.4103/0022-3859.57388
Source of Support: None, Conflict of Interest: None
Background : Parents of children with specific learning disability (SpLD) undergo stress in coping with their child's condition. Aim : To measure the levels of anxiety and find out the cause of anxiety in mothers of children with SpLD at time of diagnosis. Settings and Design : Prospective rating-scale and interview-based study conducted in our clinic. Materials and Methods : One hundred mothers of children (70 boys, 30 girls) with SpLD were interviewed using the Hamilton anxiety rating scale (HAM-A) and a semi-structured questionnaire. Detailed clinical and demographic data of mothers were noted. Statistical Analysis : Chi-square test or unpaired student's t-test was applied wherever applicable. Results : The mean age of mothers was 40.14 years (±SD 4.94, range 25.07-54.0), 73% belonged to upper or upper middle socioeconomic strata of society, 67% were graduates or postgraduates, 58% were full-time home-makers, and 33% lived in joint families. Levels of anxiety were absent in 24%, mild in 75%, and moderate in 1% of mothers. Their mean total anxiety score was 5.65 (±SD 4.75, range 0-21), mean psychic anxiety score was 3.92 (±SD 3.11, range 0-13), and mean somatic anxiety score was 1.76 (±SD 2.05, range 0-10). Their common worries were related to child's poor school performance (95%), child's future (90%), child's behavior (51%), and visits to our clinic (31%). Conclusion : Most mothers of children with SpLD have already developed mild anxiety levels by the time this hidden disability is diagnosed. These anxieties should be addressed by counseling to ensure optimum rehabilitation of these children.
Keywords: Anxiety, dyslexia, mothers, qualitative research, stress, students
Specific learning disabilities (SpLD) are a group of neurodevelopmental disorders which manifest in childhood as persistent difficulties in learning to efficiently read ("dyslexia"), write ("dysgraphia") or do simple mathematical calculations ("dyscalculia") despite normal intelligence, conventional schooling, intact hearing and vision, and adequate motivation and socio-cultural opportunity. , SpLD are presumed to be due to central nervous system dysfunction and are chronic lifelong conditions. , Children with SpLD fail to achieve school grades at a level that is commensurate with their intelligence. ,,
It is known that parents of children with SpLD are not aware of this hidden disability and undergo stress in coping with the child's condition. ,,
A detailed Medline search using the key words "anxiety" and "parents" and "dyslexia" failed to retrieve any study which has documented the anxiety levels and causes of the anxiety in parents having a child with this hidden disability. Keeping this in mind we conducted the present study whose objectives were to measure the levels of anxiety in mothers of children with SpLD at time of diagnosis, and to find out the cause of their anxiety.
The study sample was by necessity a convenience sample and first 100 mothers whose children were consecutively diagnosed with SpLD and who were conversant in English were included in the study. This study was conducted from September 2006 to May 2007. All children had been referred to our clinic for assessment of poor school performance (academic underachievement or failure). Each child was assessed over a period of two to three weeks by a multidisciplinary team comprising a pediatrician, counselor, clinical psychologist, and special educator. , The diagnosis of SpLD was confirmed by employing a locally developed curriculum-based educational test. , The diagnosis of co-occurring attention deficit hyperactivity disorder (ADHD) was made by the pediatrician and confirmed by the psychiatrist by ascertaining that the child's specific behaviors met the diagnostic and statistical manual of mental disorders-IV-revised (DSM-IV-R) criteria.  The socio-demographic characteristics of each child and parent were noted. The modified Kuppuswami's classification was used to determine the family's socioeconomic status. ,
Our study was approved by the scientific and ethics committees of our institution. All mothers had signed an informed consent form to participate in the study.
The Hamilton Anxiety Scale (HAM-A) was used to measure the levels of anxiety in the mothers and was administered by a single interviewer (NK) after undergoing adequate training under a psychiatrist (NS). , The interview was conducted in a quiet room with only the mother present and after reassuring her of confidentiality of all personal information. The HAM-A is a widely used clinician-rated symptom scale designed to quantify the severity of anxiety symptoms over the past one week and it takes about 10-15 min to complete the rating. , It is freely available in the public domain and reliability studies have shown that it measures anxiety symptoms in a consistent and valid way. 
The HAM-A consists of 14 items: (1) anxious mood, (2) tension, (3) fears, (4) insomnia, (5) intellectual impairment, (6) depressed mood, (7) somatic muscular complaints, (8) somatic sensory complaints, (9) cardiovascular symptoms, (10) respiratory symptoms, (11) gastrointestinal symptoms, (12) genitourinary symptoms, (13) autonomic symptoms, and, (14) patient's behavior at interview; each defined by a series of symptoms. Each of these 14 items is assessed by a semi-structured series of questions related to symptoms of anxiety. Each item is rated on a 5-point scale ranging from: 0 = anxiety not present; 1 = mild anxiety; 2 = moderate anxiety; 3 = severe anxiety; to 4 = very severe or grossly disabling anxiety. ,
The HAM-A provides three measures of anxiety: (i) total (overall); (ii) psychic (mental agitation and psychological distress), and (iii) somatic (physical complaints related to anxiety). Seven of the items (numbers 1-6, 14) address psychic anxiety and the remaining seven (7-13) items address somatic anxiety. A total anxiety score of ≤17 indicates mild anxiety levels; 18 to 24 moderate anxiety levels; and 25 to 30 indicates severe anxiety levels. , Studies have shown that individuals with psychiatric disorders such as anxiety disorders (generalized anxiety disorder or panic disorder) or depression have a total anxiety score of > 20 on the HAM-A. 
Lastly, each mother was interviewed using a semi-structured questionnaire to find out what was worrying her over the last one week in all areas of her life and her worries were noted ad verbatim. The interview instrument, designed for this study by the investigators, had both open-ended and close-ended questions to guide the interview. Before the study commenced, the interview instrument was critiqued for content validity and clarity by an expert in qualitative research methods. Each mother was asked whether or not she had been worrying about her child's school performance or behavior, the class teacher or school principal's behavior towards her child, her relationship with her husband or family members, the situation at her workplace (if applicable), her personal health, interacting with society because of her child's problem, visiting our clinic for her child's assessments, and about her child's future. Each interview lasted about 20-30 min. At end of the study these 100 interviews were analyzed to find out the common worries that were causing anxiety.
The data were analyzed using the Statistical Package for the Social Sciences program, version 11.0 for Windows (SPSS Ltd., Chicago, Illinois, USA). Results obtained were compared using the Chi-square test (using Yates' correction where necessary), or the unpaired student's t-test, as applicable. Wherever appropriate, with bivariate analysis the odds ratio (OR) was calculated and 95% confidence interval (CI) was estimated around the OR. A two-tailed P value of < 0.05 was considered significant.
The mean age of mothers was 40.14 years [Table 1]. Three-fourths of the mothers had already developed mild levels of anxiety by the time diagnosis of SpLD was made in their child. Most mothers were educated, currently married, belonged to upper or upper middle socioeconomic strata of society, and were from nuclear families. Majority (58%) of the mothers were home-makers. Almost one-fifths of the mothers had medical problems such as hypertension, diabetes, asthma, migraine, cervical spondylosis or arthritis for which they were taking medication. One mother was already taking treatment for depression which had developed secondary to her son's poor school performance for the last few months and her depression was now under control. There were no significant differences in the clinical and demographic data of mothers of boys with SpLD as compared to mothers of girls with SpLD.
Specific learning disabilities children characteristics
All 100 children were studying in English-medium schools situated in our city. The boys: girls ratio was 2.3:1. In a large majority (83%) of children, a diagnosis of all three types of SpLD (dyslexia, dysgraphia and dyscalculia) was made [Table 2]. Most (83%) children were already studying in the secondary school section at the time of diagnosis. Before referral to our clinic, 19% children had already been detained to repeat a class standard due to failure in their annual school examinations. There were no significant differences in the clinical and demographic data of boys with SpLD as compared to girls with SpLD.
HAM-A scores of mothers
There were no significant differences in the total, psychic, and somatic HAM-A scores or in the 14 HAM-A item scores of mothers of boys with SpLD as compared to mothers of girls with SpLD [Table 3]a and b.
Also, there were no significant differences in the total, psychic, and somatic HAM-A scores; or in the 14 HAM-A item scores of mothers irrespective of their socioeconomic status, type of family, religion, educational status, marital status, work status, and current health status.
Mothers' worries documented during questionnaire
The most common worries, in 95% of mothers, were related to their "child's chronic poor school performance", namely, getting poor marks in spite of working hard, illegible handwriting, repeated spelling mistakes, slow writing, poor reading skills, difficulty in calculations, incomplete school work, and poor memory [Table 4]. The second common worries, in 90% of mothers, were related to the "child's future", namely, whether child will be able to continue education, become a graduate, cope with higher education and have a career as a professional, and stand on his/her own feet. Almost half of the mothers (51%) were worried about their "child's behavior", namely, aggressive behavior, temper tantrums, stubbornness, hyperactivity, or inattentiveness. Almost a third (31%) of the mothers was worried about the multiple visits to our clinic for their child's assessment, namely, the tests that will be conducted on their child, and that the procedure of assessment was time-consuming. A few mothers (16%) were worried about their home situation; either marital conflicts with their husbands or relationships with other family members at home. Very few mothers were worried about their child's class teacher or school principal's behavior: 7% were worried that the class teacher criticizes their child's academic abilities in front of classmates, or is not paying adequate attention to their child; and 2% were worried that the school principal was uncaring towards their child's problem. No mother stated that she was worried about her personal health. There were no significant differences in the worries documented in mothers of boys with SpLD as compared to mothers of girls with SpLD.
The present study documents that in the city of Mumbai most mothers have already developed mild levels of anxiety by the time SpLD is diagnosed in their child. Development of maternal anxiety was not influenced by the gender of the child. Maternal anxieties were mainly related to their child's poor school performance, behavior, and future prospects in life; and making visits to our clinic for their child's assessment. To the best of our knowledge there is no study from India or anywhere in the world which has documented and analyzed the anxiety levels and anxieties of mothers of children with SpLD at the time of its diagnosis.
SpLD should be suspected by the school authorities early, when the child is in primary school, and conclusively diagnosed by the age of eight years. ,, In the present study most children were already studying in the secondary school section before the diagnosis of SpLD was made. It is well known that if SpLD remains undetected chronic poor school performance ensues. , In the present study the most common worries, in 95% of mothers, were related to their "child's chronic poor school performance" which often leads to these children losing their self-esteem, getting frustrated, and developing withdrawn or aggressive behavior. , Half of the mothers in the present study were worried about their child's behavior, namely, aggressive behavior, temper tantrums, stubbornness, hyperactivity, or inattentiveness. It is also known that about 20% of children with SpLD have associated ADHD as a co-morbidity. ,, In the present study 29% of children with SpLD had associated ADHD (SpLD/ADHD). Children with SpLD/ADHD have "more severe" learning problems than children who have SpLD but no ADHD, and also "more severe" attention problems than children who have ADHD but no SpLD.  Class detention, which had been experienced by 19% of the study children, is also known to cause severe emotional stress and lead to aggressive/ withdrawn behaviors. 
We cannot compare the present study with previous work because there aren't any. However, Waggoner and Wilgosh (Canada) have reported "concerns" of eight parents (mother or father, or both) having children with SpLD whose disability had been diagnosed earlier and were already undergoing remedial education.  They indicated getting emotionally and physically drained due to: (i) their involvement in their child's remedial education, (ii) facing school teachers who were uncooperative and unconcerned about their child's SpLD, (iii) their child getting ashamed of his/ her need to attend remedial classes, (iv) concerns for their child's future in a world which lays so much stress on academic achievements.  In the present study, mothers were not yet faced with these problems which may occur during the management of SpLD. However, most (90%) were already worried about their child's future prospects in life.
What is the utility of the present study? We believe that the results of the present study will help pediatricians, psychiatrists, and counselors address the anxieties of mothers whose children have been diagnosed with SpLD. It is known that chronic poor school performance due to undiagnosed SpLD results in the child having a low self-esteem, developing feelings of inadequacy, and becoming over-sensitive to criticism.  Chronic poor school performance also adversely impacts the child's peer and family relationships and social interactions.  Parents, especially the mother (in our society), may lose confidence in the child's ability to ever achieve academic competence, get frustrated, and develop aggressive behavior towards the child. , Chronic maternal aggressive behavior would further negatively impact the child's self-esteem, and general wellbeing. The results of the present study highlight the need to address maternal anxieties about SpLD at the time of diagnosis of the disability in the child. Mothers should be counseled in depth over a few sessions, about what is SpLD and why it results in poor school performance. Their anxieties about the child's future should be allayed by informing them that school performance improves after the child undergoes remedial education and avails the benefits of accommodations (provisions) in his/her school curriculum. , Mothers should be advised about parenting techniques to lessen the behavioral problems, if already present. If the child has associated ADHD the mother should be reassured that symptoms of hyperactivity/ inattentiveness are eminently treatable by behavioral therapy and, if necessary, with medications.  Lastly, school authorities/ secretary in a learning disability clinic should inform the mothers that the assessment is necessarily done by a team of professionals and multiple visits are therefore necessary; and about the tests done to evaluate their child. Allaying maternal anxieties early would help ensure optimum rehabilitation of these children.
Our study has its limitations. First, considering the probable prevalence of children with SpLD in our city the sample size of affected mothers is small. However, we still believe that these results are important as awareness about SpLD is still limited in our city and few children actually get diagnosed.  Second, the cross-sectional design of the present study limited us from drawing "conclusive" cause-effect relationships between child's poor school performance/ class retention and behavioral problems. Third, anxiety in some of the mothers could reflect preexisting, long-standing psychological disorders (for example, "trait anxiety") that were not caused or exacerbated by the child's SpLD. Evaluating such lifetime disorders is practically difficult because mothers are not accessible until the child is referred to our clinic for assessment. Fourth, mothers from the lower socioeconomic strata of society were few in number in our study population. Possibly, non-availability of standardized psychoeducational tests in vernacular languages led to this limitation. Fifth, certain sociodemographic factors such as environment in neighborhood, parenting style and intelligence which may influence development of maternal anxiety were not probed. Sixth, we did not include assessments of fathers as most often children are accompanied by their mothers to our clinic. Future studies should consider including fathers as well as mothers. However, we do not believe that these limitations adversely affect the utility of our results. Both due to the limitations as outlined above and the general paucity of data on anxieties of parents with children having SpLD, the implications of the present study need to be determined by future studies.
We thank Dr. DP Singh, Professor, Department of Research Methodology, Tata Institute of Social Sciences, Deonar, Mumbai, for his help in the statistical analysis of the data. We also thank the mothers who participated in the study.
[Table 1], [Table 2], [Table 3], [Table 4]