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Self-perceived anxiety symptoms in school students with borderline intellectual functioning: A cross-sectional questionnaire-based study in Mumbai, Maharashtra, India S Karande1, NJ Gogtay2, N Shaikh1, R Sholapurwala1, T More1, P Meshram11 Learning Disability Clinic, Department of Pediatrics, Seth G.S. Medical College and K.E.M. Hospital, Mumbai, Maharashtra, India 2 Department of Clinical Pharmacology, Seth G.S. Medical College and K.E.M. Hospital, Mumbai, Maharashtra, India
Correspondence Address: Source of Support: None, Conflict of Interest: None DOI: 10.4103/jpgm.jpgm_956_22
Keywords: Affective symptoms, attention-deficit/hyperactivity disorder, confounding variables, test anxiety scale, underachievement
All over the world, anxiety disorders are one of the most common psychological disorders in school students, and have been found to negatively affect their academic, social, and personal development.[1],[2] Students with borderline intellectual functioning (“slow learners”) have an intelligence quotient (IQ) score in the range of 71 to 84.[3],[4] Typically, slow learners have heterogeneous cognitive difficulties and tend to fall back in the regular classroom as the speed and methods of teaching are inappropriate for their learning ability.[5] They have academic difficulties in reading, writing, and in understanding and doing mathematics; executive function deficits, poor working memory, and often struggle in respect of social functioning.[5] A PubMed search using the medical subject headings (MeSH) words “anxiety” and “borderline intellectual functioning” did not reveal any research studies related to anxiety in slow learners in India. Hence, we conducted the present study with the primary objective of evaluating the prevalence of anxiety symptoms in slow learners seen at our institute. A secondary objective was to assess the impact of covariates on their anxiety symptoms.
Ethics The study protocol was approved by the Institutional Ethics Committee [EC/25/2020] and it was registered prospectively with the Clinical Trials Registry of India [CTRI/2020/10/028354]. It was conducted in accordance with the ethical standards laid down in the 1964 Declaration of Helsinki (Fortaleza revision, 2013); and the 2017 ethics guidelines laid down by the Indian Council of Medical Research. Accordingly, all parents signed an informed consent form permitting the participation of their child. Additionally, all school students either gave oral assent (≥8 to <12 years) or written assent (≥12 to <18 years) prior to enrolment. Confidentiality was maintained using unique identifiers. Design, setting and sample size calculation The present cross-sectional single-arm questionnaire-based study was conducted at the learning disability clinic of a public medical college in Mumbai, a megacity in western India over a period of 14 months, from October 2020 to November 2021. The prevalence of slow learners in India is unknown, but has been reported to range between 7% to 13% among populations in developed countries.[5],[6] In the present study; we assumed that 7% of students in our city would be slow learners. With a 95% confidence level and 5% precision, Daniel's formula,[7] yielded a sample size of 100. Eligibility criteria and enrolment process The study population (recruited by non-probability sampling) comprised slow learners, who were ≥8 to <18 years of age, studying in English medium schools, and who were able to read and write English, and whose parents consented for their ward to participate. No exclusion criteria that would preclude participation were used among students. Diagnosis of slow learners The pediatrician took a detailed clinical history and did a detailed clinical examination. An otolaryngologist and an ophthalmologist documented that hearing or visual impairment was <40%, if any, respectively. Each student underwent standard recommended psychological evaluation before the diagnosis of slow learner was confirmed. The clinical psychologist used the Wechsler Intelligence Scale for Children-Revised (M.C. Bhatt's Indian adaptation)[8] or Binet-Kamat Test of Intelligence[9] to determine that the student's IQ score was between 71 to 84. Using information from the student's parents and teachers, diagnosis of co-occurring attention-deficit/hyperactivity disorder (ADHD), if present, was made by ascertaining that student's specific behaviors met the required Diagnostic and Statistical Manual of Mental Disorders-5 criteria.[10] Up to 40% of slow learners have associated ADHD which is characterized by persistent hyperactivity, impulsivity, and inattention, and this comorbidity further impairs their learning.[11] Data collection Anxiety symptoms were measured using the Screen for Child Anxiety Related Disorders-Child version (SCARED-C) questionnaire.[12],[13] All students were explained on how to complete the questionnaire by a trained investigator; following which they individually completed it in a quiet room, without their parents being present. As recommended, for students aged 8 to 11 years, the interviewer read out and explained all questions prior to testing.[12],[13] Also, every enrolled student was allowed to take the help of the interviewer to further explain any question before marking his/her response.[12],[13] There was no time constraint for completing the questionnaire.[12],[13] Data related to 14 sociodemographic variables (“covariates”) were documented using a supplementary form. These variables included: (i) age (in months), (ii) gender, (iii) IQ score, (iv) duration of academic difficulties (in months), (v) birth order, (vi) being an only child, (vii) socioeconomic status, (viii) type of family, viz. “nuclear” or “joint,” (ix) co-occurring ADHD, (x) co-occurring chronic medical illness, (xi) school class standard, (xii) type of school attended, viz., “single-sex education” or “co-educational,” (xiii) school ownership, viz. “public” or “private,” and (xiv) school educational board. The socioeconomic strata were determined by the revised Kuppuswamy's socioeconomic scale.[14] It is well-known that a student with a chronic medical illness (such as asthma and epilepsy) undergoes stress due to the illness; and the ability of a student to cope with academic difficulties varies according to the type of peer pressure faced in school and the rigors of the school curriculum. Measuring anxiety symptoms The SCARED-C questionnaire is a 41-item self-report measure designed to screen for anxiety disorders in children between the ages of 8 and 18 years and is based on the DSM-IV diagnostic categories of anxiety disorders.[12],[13],[15] The measure yields “subscales” scores for “panic disorder,” “generalized anxiety disorder,” “separation anxiety disorder,” “social anxiety disorder,” and “significant school avoidance disorder”; as well as a composite “overall anxiety” (or “total anxiety”) score [Table 1].[12],[13],[15] The items on the SCARED-C test are short and simple sentences, and the children are asked to choose, based on their mood over the course of the last three months, whether the statement is “not true or hardly ever true,” “somewhat true or sometimes true,” or “very true or often true.” Each item represents one of the five subscales that the test was designed for. A cut-off score of ≥7, ≥9, ≥5, ≥8, and ≥3 (for their corresponding items) indicates the presence of symptoms of “panic disorder,” “generalized anxiety disorder,” “separation anxiety disorder,” “social anxiety disorder,” and “significant school avoidance disorder,” respectively.[12],[13] The higher the scores, the more severe the anxiety symptoms are. An “overall anxiety” score of ≥25 should raise the clinician's index of suspicion that child has anxiety and one or more of the anxiety disorders.[12] A “more specific overall anxiety” score of ≥31 further increases the likelihood that the participant has anxiety and one or more of the anxiety disorders.[13]
The SCARED-C is a reliable and valid instrument to screen for childhood anxiety disorders in clinical settings, with good internal consistency (α from 0.7 to 0.9), optimum test-retest reliability (stability coefficient from 0.6 to 0.9), and discriminant validity, both between anxiety and other psychiatric disorders and within anxiety disorders.[12] A recent meta-analysis of 65 studies (conducted utilizing the SCARED instrument between 1997 and 2017) has concluded that the child and parent versions of the SCARED have robust psychometric properties and perform consistently well in community and clinical settings across various countries.[16] The SCARED is clinically relevant as mental health providers and researchers can use it during diagnostic procedures and to monitor intervention effectiveness.[16] Data analysis Analysis was done using the Statistical Package for Social Sciences, version 25.0 for Windows (Chicago, IL, USA). The sociodemographic data were expressed using descriptive statistics. First, the SCARED-C (“individual subscales” and “overall”) scores of the slow learners were calculated as per the recommended guidelines[13] and were tested for normality using the Shapiro-Wilk test that indicated non-normal distributions. Second, in order to investigate the reliability of the SCARED-C questionnaire in the present study, internal consistencies (Cronbach's alpha) were calculated for each of the SCARED-C (“individual subscales” and “overall”) scores. Testing for reliability (“internal consistency”) involves estimating how consistently individuals respond to the items within a scale.[17],[18] Where items within a scale measure different elements of patient experience (as in the multidimensional SCARED-C tool), an acceptable Cronbach's alpha (i.e., >0.45), rather than a high alpha (i.e., ≥0.7), is to be expected.[17],[18],[19],[20] Third, the correlation coefficients (as measured by Spearman's rho) between the “individual subscales” and “overall” SCARED-C scores of the study sample were calculated. These can be used as another test of the convergent validity of the constructs.[21] Fourth, “univariate regression analysis” was carried out to evaluate the unadjusted impact of each of the 14 variables on the SCARED-C (“individual subscales,” and “overall,” and “more specific overall”) scores of the study sample. Furthermore, purposeful selection of variables (cut-off levels of P < 0.20 on the univariate analysis)[22] was done; and “multivariate regression analysis” was performed for determining the “independent” impact that these selected variables had on the SCARED-C (“individual subscales,” “overall,” and “more specific overall”) scores of the study sample. A two-tailed P value of <0.05 was considered significant.
Demographic characteristics of slow learners The median (IQR) age of students was 186 (180 – 201.5) months. The boys: girls' ratio was 2.03:1. Their median (IQR) IQ score was 77 (73 – 80). Their median (IQR) duration of academic difficulties was 48 (36 – 72) months. Only three students had a co-occurring chronic medical illness (epilepsy, hypothyroidism, and hydrocephalus, respectively). Other sociodemographic characteristics of the slow learners are shown in [Table 2]. No parent declined consent and no student declined assent for participation. Time taken by the students to fill the SCARED-C questionnaire ranged from about 20 to 40 minutes. There were no missing data for the SCARED-C items.
Anxiety disorder(s) symptoms in study participants Symptoms of all five anxiety disorder types were detected [Table 3]a; with the highest number of slow learners (40%) having symptoms of separation anxiety, followed by social anxiety in 32%, generalized anxiety in 31%, panic in 26%, and significant school avoidance in 24% [Table 3]b.
Overall anxiety symptoms in study participants Symptoms of “overall anxiety” and “more specific overall” anxiety were present in 38% and 26% of slow learners, respectively [Table 3]b. Most participants who had symptoms of one or more anxiety disorders also had “overall anxiety” and “more specific overall” anxiety symptoms, respectively [Table 3]b. Reliability of SCARED-C scores (individual subscales and overall) In the current study sample, the internal consistency was high for three subscale scores (panic disorder, alpha = 0.88; generalized anxiety disorder, alpha = 0.81; and social anxiety disorder, alpha = 0.74); and for the total SCARED-C score (i.e., alpha = 0.80). For two subscale scores, the internal consistency was acceptable (separation anxiety disorder, alpha = 0.69; and significant school avoidance disorder, alpha = 0.56). Correlations between SCARED-C subscales and overall scores [Table 4] shows the correlations between the SCARED-C subscales scores and the overall score for the whole sample. There was a highly strong relationship (Spearmen's rho = 0.5 – 1.0) between each of the subscales' scores and the “overall” score, indicating a good convergent validity for these constructs.
Impact of variables on anxiety disorder symptoms in study participants Univariate regression analysis At the univariate level: (i) older age, studying in a higher school class standard and in a single-gender educational school were significantly associated with having “panic” symptoms (P = 0.006, P = 0.004, and P = 0.045, respectively) [Table S1]; (ii) older age, being an only child, studying in a higher school class standard, in a single-gender educational school, and in a SSC/HSC (Secondary School Certificate/Higher Secondary Certificate) educational board affiliated school were significantly associated with having “generalized anxiety” symptoms (P < 0.0001, P = 0.023, P < 0.0001, P = 0.046, and P = 0.013, respectively) [Table S2]; (iii) studying in a higher school class standard and in a SSC/HSC educational board affiliated school were significantly associated with having “social anxiety” symptoms (P = 0.037, and P = 0.010, respectively) [Table S4]; (iv) older age, studying in a higher school class standard, in a single-gender educational school and in a SSC/HSC educational board affiliated school were significantly associated with having “overall anxiety” symptoms (P = 0.016, P = 0.007, P = 0.035, and P = 0.030, respectively) [Table S6]; and, (v) older age and studying in a higher school class standard were significantly associated with having “more specific overall anxiety” symptoms (P = 0.047 and P = 0.012, respectively) [Table S7]. No sociodemographic variable was significantly associated with having “separation anxiety” or “significant school avoidance” symptoms [Tables S3] and [Tables S5].
Multivariate regression analysis At the multivariate level: (i) 13.6% of variance in the “panic” symptoms was explained by the six purposefully selected sociodemographic variables [Table 5]a; and only presence of co-occurring ADHD was significantly associated with having “panic” symptoms (β = -0.20, P = 0.040) [Table 5]a; (ii) 23.6% of variance in the “generalized anxiety” symptoms was explained by the eight purposefully selected sociodemographic variables [Table 5]b; and only studying in a SSC/HSC educational board affiliated school was significantly associated with having “generalized anxiety” symptoms (β = -0.24, P = 0.009) [Table 5]b; (iii) 3.5% of variance in the “separation anxiety” symptoms was explained by the three purposefully selected sociodemographic variables [Table S8]; and no variable was significantly associated with having “separation anxiety” symptoms [Table S8]; (iv) 9.4% of variance in the “social anxiety” symptoms was explained by the five purposefully selected sociodemographic variables [Table 5]c; and only studying in a SSC/HSC educational board affiliated school was significantly associated with having “social anxiety” symptoms (β = -0.22, P = 0.026) [Table 5]c; and, (v) 13.6% of variance in the “overall anxiety” symptoms was explained by the six purposefully selected sociodemographic variables [Table 5]d; and only studying in a SSC/HSC educational board affiliated school was significantly associated with having “overall anxiety” symptoms (β = -0.20, P = 0.046) [Table 5]d. Multivariate regression analysis was not carried out for “significant school avoidance” symptoms as none of the 14 variables, on univariate analysis, had a P < 0.12 [Table S5]. None of the variables was significantly associated with having “more specific overall anxiety” symptoms [Table S9].
The present study has documented that in the city of Mumbai, western India, 24% to 40% of slow learners studying in class standards III to XII had symptoms of one or more anxiety disorders (separation anxiety > social anxiety > generalized anxiety > panic > significant school avoidance). Symptoms of overall anxiety were detected in 38% of slow learners. Slow learners having co-occurring ADHD were significantly associated with having panic symptoms; and slow learners studying in a SSC/HSC educational board affiliated school were significantly associated with having generalized, social and overall anxiety symptoms. We also found out that having any of the five anxiety disorders or overall anxiety within these slow learners was not influenced by their age, gender, level of intellectual functioning, duration of academic difficulties, birth order, being an only child, socioeconomic status, residing in a nuclear or joint family, having a co-occurring chronic medical illness, school class standard, studying in a co-educational or single gender school, or public or privately owned school. We cannot compare the present study with previous work because there is not any. A detailed Medline search did not find any study which had utilized the SCARED-C questionnaire to document anxiety symptoms in individuals with borderline intellectual functioning. Despite its sizeable prevalence, borderline intellectual functioning is a rarely studied topic not only in children but also in adults, and information on it is fragmentary.[23],[24] Melby et al.[25] (Tingvoll, Norway) have assessed young adults (19-year-olds) with borderline intellectual functioning, using the Schedule for Affective Disorder and Schizophrenia for School-age Children Present and Lifetime (K-SADS P/L) instrument, and reported that they had excess risk of anxiety. On the other hand, King et al.[26] (Melbourne, Australia) using the Children's Anxiety Scale 8-item (CAS-8) instrument have reported that adolescents with borderline intellectual functioning did not have a greater odds of reporting symptoms of anxiety. In the same study, they utilized the Strengths and Difficulties Questionnaire to measure emotional–behavioral difficulties and found that these adolescents have a higher risk of poor mental health. What are the practical implications of the present study? First, we recommend that all slow learners should be screened for anxiety without delay after their diagnosis is confirmed. There is now convincing evidence that with cognitive behavior therapy, many of the students with anxiety disorders show favorable outcomes.[27],[28] Rarely, anxiolytic medications such as selective serotonin reuptake inhibitors (SSRIs) are needed to be prescribed.[27] It is known that high levels of anxiety have a deleterious effect on academic performance.[29],[30] Also, untreated anxiety over a period of time would contribute to negative educational outcomes such as failure to complete high school and failure to enter college.[29],[30] Second, the present study has identified higher levels of specific subtypes of anxiety disorder in slow learners. This data may help the treating counselor/psychiatrist in alleviating their symptoms. Third, mental health problems (depression, psychosis, drug dependence, and suicidal behavior) are more prevalent in adults with borderline intellectual functioning than in the general population.[31],[32] Timely and effective management of the anxiety disorder(s) in slow learners when they are children may help delay onset of mental health problems in adulthood or lessen its symptoms.[31],[32] We have no proper explanation for why slow learners studying in a SSC/HSC educational board affiliated school were significantly associated with having generalized, social, and overall anxiety symptoms. The strengths of the present study include adequate sampling size, use of a validated pediatric instrument, namely the SCARED-C questionnaire to measure anxiety symptoms and high participation and response rates. Also, the reliability for three subscale scores (panic disorder, generalized anxiety disorder, and social anxiety disorder) and overall SCARED-C score in the present study was high; and for the remaining two subscales (separation anxiety disorder and significant school avoidance disorder) was acceptable. The convergent validity for all the constructs of the SCARED-C questionnaire in the present study was good. Russell et al.[33] (Vellore, India) have earlier reported that the Malayalam translation of the SCARED-C questionnaire is a valid instrument to assess anxiety disorders in Indian adolescents from the general community. A few limitations of the present study should be taken into account. First, the non-probability sampling of the present study may have led to a recruitment bias in our findings.[34] Second, boys outnumbered girls, and this could have led to an ascertainment bias in the study.[34] It is well-known that in our society more boys are referred for assessment of academic problems as parents generally have higher expectations from their sons. Second, the study relied exclusively on slow learners' self-report. Parent or teacher ratings of slow learners' anxiety symptoms might have provided important additional information. Also, no behavioral observations or clinical indices were used to confirm these self-report measures and this could have biased some of our results.[34] Future researchers should simultaneously obtain data from both slow learners and their parents (utilizing the SCARED-parent about child version) to address this shortcoming. Third, although we used a validated instrument, the SCARED-C is just an anxiety screening tool.[12],[13] Further clinical assessment by a psychiatrist would have helped in confirming the diagnosis of anxiety disorder(s)/overall anxiety; but this was beyond the scope of the study. It is possible that some of the slow learners identified with high scores may not have had clinically significant anxiety disorder(s)/overall anxiety on psychiatric evaluation. Fourth, reliability was assessed only by means of internal consistency. Other aspects of reliability such as test-retest stability and inter-rater reliability were not examined. Fifth, certain variables such as parenting style, neighborhood environment, social support, and type of social support which are well-known to influence development of anxiety symptoms was not investigated. Sixth, because non-English-speaking students were excluded from the study there may be a potential language bias in our findings. Although Hindi and Marathi-medium schools were accessible in the vicinity of our institution, the Hindi/Marathi version of the SCARED-C questionnaire was not available.[13] Sixth, including a control group of regular children in the present study would have given a better idea about the significance of these findings. However, we do not believe that these limitations have adversely affected the usefulness of our results. Due to the limitations outlined above and the general paucity of data on anxiety symptoms in Indian slow learners, future researchers should investigate whether the present study's results can be generalized to the population level.
There is an urgent need to start screening slow learners in our city for anxiety disorders and the SCARED-C questionnaire can help in this process. Early diagnosis of anxiety symptoms would help to optimize management of slow learners and may lead to favorable long-term academic and social outcomes. Acknowledgements We thank all the students and parents who participated in the present study. We thank Dr. Shruti Saha and Dr. Unnati Saxena, Department of Clinical Pharmacology, for their help in the statistical analysis of the data. We also thank the developers of the Screen for Child Anxiety Related Disorders-Child version (SCARED-C) instrument, Boris Birmaher, M.D., Suneeta Khetarpal, M.D., Marlane Cully, M.Ed., David Brent M.D., and Sandra McKenzie, Ph.D., Western Psychiatric Institute and Clinic, University of Pittsburgh, United States. The material in this publication is the result of use of the SCARED-C instrument and their assistance is gratefully acknowledged. Financial support and sponsorship The Learning Disability Clinic at our institute is partially funded by a research grant from MPS Ltd., Noida, Uttar Pradesh, India. Conflicts of interest Dr. Sunil Karande is the Editor of the Journal of Postgraduate Medicine.
[Table 1], [Table 2], [Table 3], [Table 4], [Table 5]
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