INDIAN JOURNAL OF

CLINICAL PSYCHOLOGY
Editorial Board, Journal Committee, Executive Council & Secretariat i-ii
Instructions to Authors iii-v
Volume 40, Number - 1 Editorial:
March, 2013 Statistics in Behavioural Sciences 01-03
ISSN 0303-2582 K. S. Sengar
Presidential Address:
Clinical Psychologists in General Hospital and Beyond… 04-07
Manju Mehta
Award Paper:
Conquering New Frontiers in Clinical Psychology: The Sexual Medicine 08-12
K. Promodu
Research Article:
Assessment of Neuropsychological Functions in Schizophrenia 13-22
Adarsh Kohli
Perceived Social Support among the Family Members of
Mentally Ill Patients 23-28
Sampa Sinha, Masroor Jahan and A.N. Verma
Underlying Psychological Factors among Cases under Breast Cancer Treatment
29-33
O. S. Ravindran and N. Hemalatha
Loss, Trauma and Suicidal Ideation among Women Living in a Shelter
34-40
L. N. Suman and B. V. Sesha
A Qualitative Study of Parents’ Reasoning and Decision Making
Process in Career Choice for their Children 41-48
Editor Anisha Juneja and Naveen Grover
K.S. Sengar Burden of Care and Expressed Emotion in Spouses of Chronic
Schizophrenic Patients 49-54
Sandhyarani Mohanty and Sudhir Kumar
Attitude towards Mental Illness among Students Appeared in the
Entrance Examination for Higher Degree in Mental Health 55-59
Sujit K. Mishra, Sijo George, Archana Singh, K S Sengar and Amool R. Singh
Association of Alcoholism with Personality and HIV- A Hospital
Based Study 60-62
Rupesh Choudhury and B.P. Mishra
Guidelines: Indian Association of Clinical Psychologists For
Organizing Conference of Indian Association of Clinical Psychologists 63-64
Manju Mehta, Gauri Shanker and Masroor Jahan
Practice Guidelines : Learning Disability
Annie John, Akila Sadasivan, Bhasi Sukumaran, Poornima Bhola, 65-88
Neena J. David and L. S. S. Manickam
RNI RN 26039/74 Book Review:
E D M R Therapy and Adjunct Approaches with Children
2I¿FLDO3XEOLFDWLRQRI,QGLDQ 89
Association of Clinical Psychologists Complex Trauma, Attachment and Dissociation
www.iacp.in Amool R. Singh
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INDIAN JOURNAL OF CLINICAL PSYCHOLOGY
Volume 40 March 2013 No. 1

Editor : K. S. Sengar

Editorial Board Editorial Advisory Board

Anisha Shah, (Bengaluru) A. K. Srivastava, (Kanpur)

Ashima N. Wadhawan, (Delhi) Amool R Singh, (Ranchi)

Arup Ghosal, (Kolkata)
D. K. Sharma, (Delhi)
D. P. Sen Mazumdar, (Delhi)
D. Sahoo, (Bhubaneshwar)
Janak Pandey, (Patna)
Devvrata Kumar, (Bengaluru)
M. K. Mondal, (Delhi)
J. Mahto, (Raipur) M. S. Thimappa, (Bengaluru)
K. B. Kumar, (Secunderabad) Mata Prasad (Lucknow)
K. Girish, N R . G. Sharma, (Varanasi)
K. Pramodu, (Kozikode) S. C. Gupta, (Lucknow)

Kalpana Srivastava, (Pune) T. B. Singh, (Ahmedabad)

L. S. S. Manickam, (Mysore) Distinguished Former Editors

M. Akshay Kumar Singh, (Imphal) S. K. Verma, (1974 – 1983)
Maitreyee Dutta, (Tezpur) S. K. Maudgil, (1984 – 1986)
Manjari Srivastava, (Mumbai) S. C. Gupta, (1987 – 1889)

N. G. Desai, (Delhi) D. K. Menon, (1990 – 1991)

R. Kishore, (1992)
Rajeev Dogra, (Rohtak)
K. Dutt, (1993)
Rakesh Kumar, (Agra)
K. Rangaswami, (1994 – 1995)
S. L. Vaya, (Gandhi Nagar)
S S Nathawat, (1996 – 2002)
U K Sinha, (Delhi) Amool R Singh, (2002 – 2006)
Ashima N Wadhawan, (2007)
Statistical Consultant S P K Jena, (2008- 2011)
Ram C Bajpai, (Delhi)

i
 JOURNAL COMMITTEE
B. Balakrishnan, (Chennai) Jashobanta Mohapatra, (Cuttuk)
P T Sasi, (Thrissur) Jai Prakash, (Ranchi)
Masroor Jahan, (Ranchi)
([2I¿FLR0HPEHU

EXECUTIVE COUNCIL
President President Elect
Manju Mehta, V. C. George,
AIIMS, New Delhi Miraj
georgevadaketh@yahoo.com
iacpprez@gmail.com
Immediate Past President Hon. General Secretary
Dr. Malvika Kapoor, Bengaluru Masroor Jahan
malvikakapoor@yahoo.co.in RINPAS, Kanke, Ranchi–834006 (Jharkhand)
iacpsecretary@gmail.com

Immediate Past Hon. Gen. Secretary Treasurer

Dr. L. S. S. Manickam Adarsh Kohli
JSS Medical College Hospital, Mysore PGIME & R., Chandigarh
iacppastsecretary@gmail.com adiuska5@yahoo.co.in

COUNCIL MEMBERS
All India East Zone
Dherendra Kumar Tilottama Mukherjee
tmcaluni@rediffmail.com
dpsychologist@yahoo.com
Jashobanta Mohapatra
N Suresh Kumar jashobanta.orissa@gmail.com
nsureshkumar@gmail.com

West Zone North Zone

Nilesh Wagh Ashima Nehra
waghneelesh@gmail.com ashimanehra@gmail.com
Swati Kedia
Ranjeet Kumar (Gwalior) swati:nabshtra@gmail.com

South Zone President Nominee

C Venkat Subbbaiah Savita Sapra
venkatclinpsy@gmail.com
Manoj Sharma
SECRETARIAT
Department of Clinical Psychology, Ranchi Institute of Neuro-Psychiatry and Allied Sciences
(RINPAS), Kanke, Ranchi – 834006 (Jharkhand), India.

ii
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Singh., R. S., & Oberhummer, I. (1980).
Behaviour therapy within a setting of karma
yoga. Journal of Behaviour Therapy and
Experimental Psychiatry,11, 135-141
Kharitonov, S.A., & Barnes, P. J.(in Press),
Behavioural and social adjustment. Journal of
Personality and Social Psychology.
Jones, X. (1996). Prevalence of Mental &
Behavioural disorder. In Proceedings of the
First National Conference of World Psychiatry
Association, 27-30 June; Baltimore. Edited by Smith
Y. Sumeham:Butter\vorth-Heinemann; pp. 16-27.
Pandit, A. K. & Verma, R S. (2005). Suicidal
behaviour and attitudes towards suicide among
students in India and Netherlands: A cross cultural
comparison. In R.F.W. Diekstra, R. Maris, S.
Platt, A. Schmidtke & G. Sonneck (Eds.) Suicide
and its prevention: The role of attitude and
intuition, (pp. 144-159), London: E.J. Brill.
f. Entire issue or Special Section of Journal
Ponder, B. Johnston, S., Chodosh, L. (Eds.)
(2006). Innovative oncology. In Breast Cancer
Research. 10, 1-72.
g. Whole Conference Proceedings
Smith, Y. (Ed) (1996). Proceedings of the
First National Conference of World Psychiatry
Association, 27-30 June : Baltimore. Edited by
Stoneham : Butterworth-Heinemann. Pp 16-27.
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Margulis, L. (2005) Cognitive Sciences. New
Haven: Yale University Press.
i. Monograph or Book in a series
Gupta, S.C., & Sethi B.B. (1987). Psychiatric
Mobidity in Uttar Pradesh. Monograph of
Culture & Society, 10 (1, Serial No. - 25).
j. Technical & Research Reports
Shankar, M., Dutta, K., Tiwari, A. K. (1995).
Mental Health in Schools (DGHS Publication
No. 10, 2), Delhi. Govt. Printing Press.
k. Ph. D. Thesis
Kohavi, R. (1995). Psychosocial function in
diabetics, Ph.D. thesis. All India Institute of
Medical Sciences. New Delhi.
I. Link/URL
Morse, S.S. (1995). Factors in the emergence
of infectious diseases. F^merg Infect Dis [serial
on the Internet]Jan-Mar [cited 1996 Jun 5); 1(1).
Available from: URL: http://www.cdc.gov/ncidod/
EID/eid.htm.
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 INDIAN JOURNAL OF CLINICAL PSYCHOLOGY
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vi
Indian Journal of Clinical Psychology
2013, Vol. 40, No. 1, 1-3
Editorial
Statistics in Behavioural Sciences
K.S. Sengar
³6WDWLVWLFDO7KLQNLQJZLOO2QH'D\DV1HFHVVDU\IRU(I¿FLHQW&LWL]HQVKLSDVWKH$ELOLW\WR5HDGDQG:ULWH´+*:HOOV
The word statistics means different things
to different people. To behavioural scientist, it
is typically a shortened version of the phrase
statistical procedures which are computation
performed as part of research. The answers
obtained by performing certain statistical
procedures are also called statistics. Thus, the
word ³67$7,67,&6´ refers both to statistical
procedure and to the answer obtained from those
procedures.
The earliest form of what is now considered
statistical analysis was developed by Pythagoras
in the 6th century BC. This was forerunner of
descriptive statistics. The other type of statistics
analysis (inferential statistics) is thought to
KDYH ¿UVW GHYHORSHG LQ WKH 2ULHQW DURXQG 
BC. (Dudycha & Dudycha, 1972). This was a
form of probability analysis used in assessing
whether an expected child was likely to be male
or female. Probability theory as it would come
to be known, continued in the form of gambling
mathematics in the work of Blaise Pascal (1623
- 1662) and Lord Christianus Huygens (1629 –
1695) (David, 1962). In the late 1800 and early
1900 many other method of descriptive statistics
were postulated. Sir Francis Galton (1883) and
Carl Pearson (1895) names were pioneer in this
area. The use of statistics was gradually shifted
from gambling to study of political and economic
issues and a new term was coined as SROLWLFDO
VWDWLVWLFV and ¿UVW LW ZDV XVHG E\ -RKQ *UDXQW
(1662). Some researchers are in favor of giving
credit to Yule (1905) for using the term statistics
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coining term goes to Eberhard August Wilhelm
Von Zimmerman in the preface of political
survey of the present state of Europe (1787). The
modern use of term Statistics is often attributed
to R A Fisher and his work “Statistical Method
for Research Workers (1925)” wherein he stated
that ³D VWDWLVWLFV LV YDOXH FDOFXODWHG IURP DQ
1
Copyright, 2013 Indian Association of
Clinical Psychologists (ISSN 0303-2582)
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WKHSRSXODWLRQIURPZKLFKLWLVGUDZQ´
Statistics is a discipline that deals with
data: summarizing them, organizing them,
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to 1850 the word statistics simply referred to
set of facts, usually numerical, that described
aspect of the state. During the 20th century, as
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Jerry Neyman, Egon Pearson, John Tukey, and
others, the term came to be used much more
broadly to include theories and techniques for
the presentation and analysis of such data and
for drawing inferences from them.
The statistics today refers either to
quantitative information or to a method
of dealing with quantitative or qualitative
information. Science with statistics bears good
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has no root. The statistics is the art of drawing
conclusions about phenomena in which chance
plays role. The randomness arise through a
variety of reasons: the intrinsic random nature
of a phenomenon, unavoidable noise in an
experiments, conscious randomization of an
experimental units or as best approximation
to reality.. The chance phenomenon occur in
broad range of situations and it has rendered
the statistical science a highly multidisciplinary
undertaking but with a core body of concept
and methods that are common to the diverse
applications. The procedures of statistics use
for the life sciences known as biostatistics,
deals with method of data analysis for clinical
and epidemiological research (e.g. survival
analysis). The classical foundation of statistics
was started by work of Fisher (Founding Father
of statistics) with the research in the area of
genetics and genomics.
It is no exaggeration to say that
all empirical research in the area of social
 K. S. Sengar
and behavioural sciences presently relies
predominantly on statistical analysis. The use
of statistics in educational and psychological
testing is known as psychometrics and in the
area of science and technology VFLHQWRPHWULFV
and ELELOLRPHWULFV In the quantitative study of
stylistic forms and patterns in the use of language
is VW\ORPHWULFV. In recent past many more areas
have been dealing with statistics as VHQVRPHWULFV
(quantitative study of taste and smell), FOLRPHWLUFV
(quantitative study of history) and MXULPHWULFV
(empirical approach to the law). The common use
of the term ³PHWULFV´ illustrates the importance of
measurement problems in these areas.
Most people know that statistics involve
math, but they don’t know that studying statistics
is much more interesting and educational than
merely cranking out a bunch of math problems.
Statistics open up new vistas in how to think,
reason and apply logic, especially it comes to
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It also make to learn new way of simplifying
enormous complexities, which will allow to
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master an important mental discipline. Moreover
statistics can be fun! Statistics are challenging,
there is elegance to their logic and you can do
nifty things with them.
The term statistics is often misunderstood
because there are actually two practical
DSSOLFDWLRQRILW7KH¿UVWUHÀHFWLQJWKHKLVWRU\RI
the term, is collection of data ----- often expressed
in summary form – that is collected and preserved.
The second application is the method of analyzing
data. These methods allow researcher to think
logically about the data and to do one of the two
things: to come to some succinct and meaningful
conclusions about the data (descriptive statistics)
or it determine – or infer- characteristics of large
group based on the data collected on small parts
(sample) of the group (inferential statistics).
Statistical analysis is the workhorse of discovery
DQG NQRZOHGJH 7KH VFLHQWL¿F SURFHVV XVLQJ
research to test theory requires that empirical
evidence (data) drawn from the research
subjects must be examined systematically. The
use of mathematics in general and statistics in
2
particular allows researchers to make these
comparisons and to discover new information
that will provide a better understanding of the
subject.
Statistics is often misused, but this has
QR UHÀHFWLRQ RQ VWDWLVWLFV DV D VFLHQWL¿F WRRO
Statistical laws are exact. This may be the
reason to give the strength to popular saying
“6WDWLVWLFV LV WKH %LJJHVW /DZ RI WKH :RUOG´
Statistical analysis should be planned along
with data collection procedure so that they
match. Most often the researcher in behavioural
sciences does not bother to use the appropriate
measures of statistics necessarily on many steps
of research e.g. the demand of data for statistical
WRROV W\SHV RI PHDVXUHV TXDQWL¿FDWLRQ RI
sample size etc. It is evident from the researches
WKDWVLPSO\ZLWKRXWDSSO\LQJDQ\VSHFL¿FORJLF
UHVHDUFKHULQEHKDYLRXUDORUVRFLDOVFLHQFHV¿[
up the sample size spontaneously for control
and experimental group by just keeping in mind
about the complexity of the problem selected
for research, availability of sample and also
the convenience of data collection procedurally
and institutionally as well. It is mandatory for
the quality research to determine sample size
by standardized statistical procedures meant
for sample size determination, for estimation of
mean, proportion or comparing of two means or
proportion. Various statistical tools e.g. Power
Analysis, Lost Value Analysis, if any, may be
used for such situation. In behavioural sciences
research before processing the data it is always
mandatory to see the nature of the data whether
the obtained data is skewed or kurtose and for
WKDW SXUSRVH FHUWDLQ VSHFL¿F SURFHGXUHV KDYH
been devised. If it is so that may restrict the use of
particular statistical tool which has been planned.
Generally these issues are being overlooked by
researcher when conducting the research. The
use of statistical tools and techniques have also
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scale for describing one group, Mean and SD,
IRU ¿QGLQJ UHODWLRQVKLS EHWZHHQ WZR YDULDEOHV
Pearosn Correlation, for predicting value from
one to other measured variable Simple Linear
or Non Linear Regression procedure is advised.
 K. S. Sengar
For comparison one group to hypothetical
value one sample t test, two unpaired group
- unpaired t test, comparing two paired group,
paired t test and for comparing three or more
unmatched group One Way ANOVA is advised
to exercise. The same is not applicable if data
is on Ordinal or Nominal scale. Rather Median,
Range, Spearman Correlation, Non-parametric
Regressin, Wilcoxon Rank Sum test, Man
Whitney test, Wilcoxon test, Kruskal Wallies
test are the appropriate choice for describing
RQH JURXS ¿QGLQJ UHODWLRQVKLS EHWZHHQ WZR
The secret language of statistics is
so appealing in a fact – minded culture, is
HPSOR\HGWRVHQVDWLRQDOLVHLQÀDWHFRQIXVHDQG
oversimplify. Statistical methods and statistical
terms are necessary in reporting the mass data of
social and economic trends, business conditions,
‘opinion polls’ the census. But without
writers who use the word with honesty and
understanding and readers who know what they
mean, the result can only be semantic nonsense.
6WDWLVWLFV LV MXVW DQRWKHU ZD\ RI QHYHU
KDYLQJWRVD\\RXDUHVRUU\
variables, predicting the another measured
variable, comparing a group to a hypothetical
value, comparing two paired group and three
or more unmatched group respectively when
data is on Ordinal scale. On the other hand when
data has been collected on Nominal scale the
3URSRUWLRQ &RQWLQJHQF\ &RHI¿FLHQW 6LPSOH
Logistic Regression, Chi Squire or Bio nominal
test, Fisher's test and Mc Nemer's test are best
FKRLFHV IRU GHVFULELQJ RQH JURXS ¿QGLQJ
relationship between two variables, predicting
value for another measured variable, comparing
a group to a hypothetical value, comparing
two unpaired groups and / or comparing three
or more unmatched groups respectively. In
some cases the use of statistical tools become
a great problem for researcher because of the
distribution and their limit to use of various
appropriate statistical tools. In such cases many
time either researcher uses the statistics by his
own choice just by overlooking the fact and need
of the data or drop the idea to use the particular
powerful statistical tool for ascertaining the
³,KDYHDJUHDWVXEMHFW6WDWLVWLFVWRZULWH
XSRQEXWIHHONHHQO\P\OLWHUDF\LQFDSDFLW\WR
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GHDWKVLVDVWDWLVWLF´±-RVHSK6WDOLQ
REFERENCES:
David. F. N. (1962). The logic of Modern Physics. New
York: Macmillan
Dudhicha, A. L. and L W Dudhicha (1972). Behavioural
statistics: an historical perspective. In R E
Kirk (ed.) Statistical Issues: A Reader for the
Behavioural Sciences3DFL¿F*URYH&$%URRNV
/Cole.
Fisher, R A. (1925). Statistical Methods for Research
Workers, 11th ed. Edinburgh: Oliver &Boyd.
Galton, F. (1883). Inquiries into Human Faculty and its
Developments. London: Macmillan.
Graunt, J. (1962). Observation on the London Bills of
Mortality of the Royal Society of London, Series
A, Vol. 186. London: Cambridge University Press.
results. In such instances the Central Limit
Theorem developed by Laplac in 1810 provides
researchers with an empirically proven concept
that allows estimates and generalization based
on a sample to be inferred to the population from
which the sample was drawn.
So, it is with much you read and hear.
Averages and relationship and trends and graphs
are not always what they seem. There may be
more in them than meet the eye, and there may
be a good deal less.
3
 3HDUVRQ .  &ODVVL¿FDWLRQ RI DV\PPHWULFDO
frequency curve in general: a types actually
occurring. Philosophical Transactions of the
Royal Society of London, Series A, Vol.186.
London: Cambridge University Press.
Yule, G. U. (1905). The introduction of the word
“Statistics”, “Statistical” into the English
Language. Journal of Royal Statistical Society,
68, 391 -396.
Zimmerman, E. A. W Von (1787). A Political Survey
of the Present State of Europe. London Royal
Statistical Society.
Indian Journal of Clinical Psychology
2013, Vol. 40, No. 1, 4-7
Presidential Address
Clinical Psychologists in General Hospital and Beyond…
Manju Mehta
Training of clinical psychologist is generally
carried out in psychiatric set up. As a result, young
psychologists seek job opportunities within the
same, especially in mental health institutions. It
is frequently overlooked that many opportunities
are present within the general hospital setup.
Working in a general hospital setup requires varied
roles and different skill in working. General
Hospitals – ranging from teaching / non teaching
institutes, government hospitals, private hospitals
and polyclinics – entail different responsibility for
clinical psychologists. While research and teaching
are at the forefront in teaching institutes, other
institutes may focus more on clinical practice.
Health is best understood in terms of a
combination of biological, psychological, and
social factors rather than purely in biological
terms. This approach known as biopsychosocial
paradigm is also a technical term for the popular
concept of the “mind–body connection “.This is
in contrast to the traditional biomedical model of
medicine that suggests every disease process can
be explained in terms of an underlying deviation
from normal function such as a pathogen, genetic
or developmental abnormality, or injury. This
model theorized by psychiatrist George L. Engel
systematically considers biological, psychological,
and social factors and their complex interactions
in understanding health, illness, and health care
delivery. Therefore, both life sciences and social
sciences are ‘basic’ to medical practice.
Biopsychosocial approach in clinical
x
practice includes:
Understanding that biopsychosocial rela-
x
tionships are central to providing health care
Eliciting the patient’s history in the context
x
of life circumstances
Using self-awareness as a diagnostic and
x
therapeutic tool
Deciding which aspects of biological,
Professor, Clinical Psychology, Department of Psychiatry, All India Institute of Medical Sciences, New Delhi
Delivered on 39th Annual National Conference of Indian Association of Clinical Psychologist held at AIIMS, New
Delhi on 24th - 26th February, 2012
4
Copyright, 2013 Indian Association of
Clinical Psychologists (ISSN 0303-2582)
psychological, and social domains are most
important to understanding and promoting
x
the patient’s health
Providing multidimensional treatment
This approach to understanding health and
diseases makes it essential for psychologists to
take on a multidisciplinary role.
Roles of a Clinical Psychologist in the general
hospital setup:
The role of a clinical psychologist in the
general hospital setup is very challenging, does not
restrict itself to pure clinical work and patient care
– but extends to teaching and research.
As a Clinician, a clinical psychologist
plays a multidisciplinary role in that he/ she
deals with a variety of not only psychiatric but
also medical conditions. There are referrals from
many disciplines like- ENT, Physical Medicine
and Rehabilitation, Endocrinology, Dermatology,
Neurology, Oncology, Cardiology, Paediatric,
Paediatric surgery and so on. They are involved
in a large array of assessments, and providing
counselling, psycho-education, and psychotherapy.
Now well established hospitals have post of
clinical psychologist. Many chronic medical
conditions lead to anxiety and depressive mood.
There are many studies indicating high prevalence
of depression in patients with terminal illness,
painful and chronic conditions The following case
would illustrate the importance of psychosocial
factors in management. A young college going girl
was referred from dermatology for not attending
college and poor prognosis in management of acne.
On psychological assessment the girl was having
depressive feelings, lack of self esteem and fear of
facing people because of acne on the face. CBT
helped her to reduce her anxiety, depression and
LQGHYHORSLQJVHOIFRQ¿GHQFH7KURXJKFRJQLWLYH
restructuring she was made to accept her illness as
a normal course in developmental period. Change
 Manju Mehta / Clinical Psychologists in General Hospital and beyond…
in her mental state helped her acne recover faster.
With increased prevalence of life style diseases
there is more demand for psychological therapies.
One needs to devise simple methods for
assessment and plan treatment for various medical
conditions. A wide range of skills and techniques
need to be used for effective therapy for different
psychiatric and medical conditions. While dealing
with medical conditions, the clinical psychologist
has to design and impart adjustment programs
to deal with chronic disease. Training programs
for coping with hospitalization process, to have
a good adaptation, programmes directed for
dealing with stressful diagnostic or treatment
events are being carried out at some places.
In clinical practice, often Clinical
Psychologists have to take some decisions
independently, these are –
x
Decision about problem for which the
referral has been sent whether has an
x
underlying psychological concern?
x
How the problem will be objectively assessed?
x
Indication of the psychological treatment.
Does one have the competence to mange
that problem?
The clinical psychologist should have professional
and ethical approach in handling these cases.
As a Teacher :
Clinical psychologists are involved in teaching
at various levels – graduate and postgraduate in
medicine, psychiatry, supervised training of clinical
psychology trainees, nursing and physiotherapy. .
The psychology teaching can be foundation
course and applied course. Foundation courses
impart basic education about the principles of
general psychology and training in various forms
of assessment and therapy. The areas important
for teaching are: learning, memory , motivation,
intelligence, personality, psychopathology,
abnormal psychology, clinical assessment,
psychodiagnosis, nonpharmacological intervention
and community interventions
Applied courses offered in many universities
incorporate practical training and internship as a
compulsory aspect of the program. They include
5
GLYHUVH DQG XSFRPLQJ ¿HOGV VXFK DV HGXFDWLRQDO
technology.
Within the general hospital setup, clinical
psychologists are involved in carrying out various
training workshops for students and staff of the hospital.
These may include workshops for skill enhancement
in the areas of communication, professional ethics,
assertiveness training, stress management.
As a Researcher :
Biopsychosocial approach to medical
disorder has lead to involvement of clinical
psychologists in many research projects. For
objective measurement of psychological factors
number of psychological tests are being used in
medical research. The clinical psychologist has to
be well versed with various tests which are easy to
administer by medical personnel.
Research could vary from developing test
materials, establishing psychometric properties of
WHVWV HYDOXDWLQJ HI¿FDF\ RI GLIIHUHQW WKHUDSHXWLF
approaches. As a clinical psychologist, not only it is
important to be well versed with research methodology
but also association of psychosocial factors in medical
disorders. One should also be able to evaluate and
LQFRUSRUDWH UHFHQW DQG PRUH HI¿FDFLRXV DVVHVVPHQW
tools and empirically tested therapies.
Within the general hospital setup,
interdisciplinary research forms a major part.
Clinical psychologists are included in research
team and also act as guides and co-guides for
research carried out in psychiatry, as well as in
other disciplines such as neurology, dermatology,
oncology, medicine, endocrinology, ophthalmology,
gynaecology paediatrics amongst many others. Apart
from research dissertation, clinical psychologists
are also involved in externally funded projects
collaborating with a wide range of agencies.
Moving beyond traditional roles...
Community Outreach Programmes :
At the community level, clinical psychologists
have both a preventive and a promotive focus. Apart
from increasing awareness and psycho-educating
the community regarding various mental health
disorders and practices, it involves an understanding
of the problems of people with risk practices. It
 Manju Mehta / Clinical Psychologists in General Hospital and beyond…
entails fostering and promoting health habits in Clinical psychologists are also helping their
population; and promoting better access to mental fellow faculty members in becoming student
health care thereby improving treatment seeking. counselors. This also includes how to do early
Working in school mental health is an example LGHQWL¿FDWLRQ RI SUREOHPV WR EH IDFLOLWDWRUV DQG
of community outreach programme. Training in motivators to empower students to develop learning
life skills and coping skills in school students is and study skills and handling their emotional
implemented in some schools in metro cities. problems.
As part of public awareness programs, clinical Administrative Role :
psychologists now also have the opportunity to be Clinical psychologists play the role of an
involved with print and digital media via radio and expert in human behaviour, personal interaction
television programmes, news articles, blogs etc. and group dynamics, and offer their services
to facilitate outreach and disseminate information as activities coordinator and advisor to solve
regarding mental health care practices. SURVSHFWLYHGLI¿FXOWLHVHPHUJLQJIURPLQWHUDFWLRQ
Screening and Training for Expedition Another task as an expert in medical boards is to
Members: give advice to personnel management authorities,
In General Hospitals there are requests to screen how to handle problems related to management,
selected candidates participating in the expeditions. GLVFLSOLQHDQGFRQÀLFWUHVROXWLRQ
Clinical psychologists are involved in screening Clinical Psychologists may also be involved
for psychological issues and concerns among those as members of decision making bodies such
going for overseas expeditions such as to Antarctica, as selection boards for recruitment of staff and
Screening process involves ruling out any form of students. They may be involved in medical boards
psychopathology along with any concerns regarding for counselling of new recruits, management of
interpersonal functioning, anxiety, adjustment issues LQWHUSHUVRQDO FRQÀLFWV DQG FRXQVHOOLQJ RI VWDII
as well as stress and coping. A thorough assessment and students with interpersonal, academic or
of personality variables may also be carried out. A behavioural issues.
variety of projective and self report measures are Medico-legal Functions :
used for the same. Clinical psychologists in the general hospital
Training is imparted to facilitate better setup are an integral part of the medical board for
adjustment, coping skills, and dealing with long medico legal proceedings carried out within the
periods of loneliness while on the expedition. hospital. They have to do objective psychological
assessment and reporting of medico legal cases,
Student Mental Health : 7KH\DUHDOVRLQYROYHGLQJLYLQJFHUWL¿FDWHVIRU
In the teaching in general hospital setup, the FRQGLWLRQV VXFK DV PHQWDO UHWDUGDWLRQ VSHFL¿F
role of the clinical psychologist extends to a student learning disability etc. For medico legal cases
advisor. Such a role includes not only counselling such as those involving divorce, custody etc.
regarding varied issues such as concentration are referred from courts directly to the clinical
GLI¿FXOW\ DFDGHPLF SUREOHPV LQWHUSHUVRQDO psychologist and he/ she is required to report to the
concerns, stress and adjustment issues; but also FRXUW ZLWK ¿QGLQJV DQG WHVWLI\ ZKHQ VXPPRQHG
workshops and training programmes to help deal Often, children undergoing custody hearings are
with some of these important issues on a larger referred to the clinical psychologist for counselling
to deal with any concerns that might surface from
scale. Regular workshops on study skills and
the child being exposed to trauma.
communication skills are a major aid in reducing
academic stress in institutes of higher learning. Challenges and Concerns in the Practice of
Anti- ragging workshops are an important part of Clinical Psychology :
the clinical psychologist’s role as a student mental The practice of clinical psychology within
health advisor. the general hospitals in the country is a relatively

6
 Manju Mehta / Clinical Psychologists in General Hospital and beyond…
recent phenomenon, dating back only a few
GHFDGHV ,W LV WKHQ QDWXUDO WKDW WKH ¿HOG ZRXOG
experience certain challenges and concerns in its
practice during its developmental years.
It is, therefore, essential for clinical
psychologists to employ a certain degree of
ÀH[LELOLW\DQGFUHDWLYLW\LQWKHLUDSSURDFKWRSUDFWLFH
Since an integral part of clinical psychology is its
collaborative work with psychiatry, it is essential
that a clinical psychologist take part in team work,
on both medical and non medical issues.
However, collaborative work makes it
essential for the professional to have a clear
understanding and in depth knowledge of both
historical and current professional issues. Self
awareness and acceptance are important for
successful interpersonal relationships which
aid in healthy working atmosphere and greater
output. It is essential in a collaborative effort for
the psychologist to be assertive, yet stay within the
realms of his/ her professional boundaries.
7KH¿HOGEHLQJLQLWVQDVFHQWVWDJHVWKHUHLV
scope for ambiguity in practice and professional
issues. A major upcoming concern is that of
ethical practice. A number of ethical concerns
may arise in the various settings in which a
clinical psychologist may work such as a hospital
environment or private practice. There are several
laws in place to control how psychology is used
DQG WKH PDMRULW\ RI WKHVH ODZV VSHFL¿FDOO\ FRYHU
various ethical problems for anyone working in the
¿HOGRIFOLQLFDOSV\FKRORJ\7KHFRGHRIFRQGXFW
and ethical principles are the ethics that outline
the responsibilities of a clinical psychologist.
They establish what behaviour and actions are
considered to be acceptable as well as unacceptable
for the practice of clinical psychology. The ethics
code is multi- dimensional and the psychologist
must adhere to the code of conduct in order to
keep their registration. The ethical principles were
SXW LQ SODFH QRW RQO\ IRU WKH EHQH¿W RI PHQWDO
health professionals, but to protect the clients, the
families, associates and the general public. The
code of ethics was created to protect the public and
the psychologist from any abuses that are the result
RIPLVKDQGOLQJDVLWXDWLRQ3K\VLFDO¿QDQFLDODQG
7
emotional situations are all protected with the
code of ethics. Ethical codes strictly regulate the
behaviours and situations resulting in malpractice.
The conduct codes and principles of ethics are put
in place to ensure that anyone receiving services
from a clinical psychologist is protected against
any breach of conduct that may cause physical or
emotional harm to those involved in the services.
To sum up role of clinical psychologist
in general hospital set up has a vast scope with
opportunity to prove importance of our profession.
One can take challenge to be creative and to satisfy
one’s own achievement needs by meeting the
demands of community and hospital population..
The success of working in general hospital set
up lies in accepting oneself, passion and pride
for the profession. One should be assertive but
not aggressive, anxious or feel inferior while
interacting with medical colleagues. Maintaining
professional boundaries is very essential.
Suggested Reading :
DiMatteo, M.R., Haskard, K.B., Williams, S.L. (2007).
“Health beliefs, disease severity, and patient
adherence: A meta-analysis”. Medical Care, 45,
521–528.
Engel, George L. (1977). “The need for a new medical
model: A challenge for biomedicine”. Science,
196, 129–136. ISSN 0036-8075 (print) / ISSN
1095-9203 (web)doi:10.1126/science.847460
Halligan, P.W., & Aylward, M. (Eds.) (2006). “The
3RZHURI%HOLHI3V\FKRVRFLDO,QÀXHQFHRQ,OOQHVV
Disability and Medicine”. Oxford University
Press, UK
McLaren N (2002). “The myth of the biopsychosocial
model”. Australian and New Zealand Journal of
Psychiatry. 36 (5), 701–703.
Sarno, John E. MD (1998). “The Mindbody Prescription:
Healing the Body, Healing the Pain.”[1]Warner
Books Inc., New York.
Santrock, J. W. (2007). A Topical Approach to Human
Life-span Development (3rd ed.). St. Louis, MO,
McGraw-Hill.
Indian Journal of Clinical Psychology Copyright, 2013 Indian Association of
2013, Vol. 40, No. 1, 8-12 Clinical Psychologists (ISSN 0303-2582)

Award Paper
Conquering New Frontiers in Clinical Psychology: The Sexual Medicine
K. Promodu
ABSTRACT
Sexuality is one of the fundamental and integral aspects of human beings. The term sexual
dysfunction denotes the various ways in which an individual is unable to participate successfully or
satisfactorily in the sexual relationship. Psychological and somatic processes are usually involved in
the causation of sexual dysfunction. Hence no single expert can deal with sexual problems adequately
DQGVFLHQWL¿FDOO\DVWKHVHDUHVWHPPLQJRXWIURPPXOWLIDFWRULDOHWLRORJ\$PXOWLGLVFLSOLQDU\WHDP
is inevitable to arrive at the correct diagnosis and effective management of sexual problems. This
concept inspired the author to establish Dr. Promodu’s Institute of Sexual & Marital Health in 2006
in Kochi exclusively for the management of sexual dysfunction. From 31st January 2006 to 31st
January 2012, a total of 12,718 new cases were seen. These patients belong to various diagnostic
categories comprising of different age groups, genders, marital status, socioeconomic background,
languages, cultures, hailing from different parts of the country and a few foreigners. Out of the
12,718 patients, 10,977 comprise of 9,605 (87.5%) men and 1,372 (12.5%) women had sexual
problems. The common sexual dysfunctions for which men sought treatment are erectile dysfunction
(ED) (63.10%), premature ejaculation (30.40%), male orgasmic dysfunction (3.27%), sexual desire
disorder (2.96%), sexual aversion disorder (0.28%) and excessive sexual desire (0.01%). Analysis of
1372 women shows that vaginismus (59.06%) is the most common sexual dysfunction among women
for which treatment was sought followed by female orgasmic dysfunction (12.58%), female sexual
desire disorder (11.83%), female sexual arousal disorder (6.93%), dyspareunia (5.97%) and female
sexual aversion disorder (3.52%). Thirty percent of the cases were treated with medicines alone,
34% with a combination of medicine and psychological intervention, 11% with sex therapy alone,
10% with cognitive behaviour therapy and 5% with surgery. In short psychological intervention
either alone or in combination was used in 55% cases. Results show that the overall recovery rate
LVKDGIXOOUHFRYHU\DQGKDGVLJQL¿FDQWV\PSWRPDWLFLPSURYHPHQW7KHSDWLHQWV
ZKRGLGQRWJHWDQ\VLJQL¿FDQWLPSURYHPHQWDQGWKHGURSRXWVWRJHWKHUDFFRXQWVIRU7KHVH
¿QGLQJVQRWRQO\GHPRQVWUDWHWKHUHOHYDQFHRISV\FKRORJLFDOLQWHUYHQWLRQHVSHFLDOO\VH[WKHUDS\EXW
also highlights the importance of a comprehensive multidisciplinary model in the management of
human sexual problems and concerns.
Key Work : Sexuality, Premature Ejaculation, Woman, Men, Arousal Disorder, Orgasmic Dysfunction

The science of psychology is broad and Clinical psychologists often work in

diverse. Many branches have emerged during
the study of human brain, mind and behaviour.
Each branch addresses problems from different
perspectives with its own focus. Clinical
psychology is the largest branch of psychology
dealing with the assessment, diagnosis, treatment
and prevention of mental disorders. Sub
specialities include child mental health, adult
mental health, emotional problems, learning
disabilities, sexual health, family and marital
problems, substance abuse, geriatric problems,
health psychology etc.
medical settings but do not treat with medication,
instead use various psychological methods and
tools from their armamentarium to carry out
assessment, diagnosis and treatment. Focus today
is on the sexual health, especially against the
backdrop of the gruesome gang rape case in Delhi
which received nationwide attention and evoked
disquiet and anger on a scale never seen before.
It is to be noted that between 2007 and 2011,
Delhi saw 2,620 rape cases while Mumbai had
1,033, Bangalore 383, Chennai 293 and Kolkata
200 cases (Nanda, 2013). Kerala is no exception

Clinical Psychologist & Sex Therapist, Chairman & Managing Director, Dr. Promodu’s Institute of Sexual & Marital Health Pvt.
Ltd., Kochi - 682024, Website: www.drpromodusinstitute.in, Email: drpromodu@yahoo.com,info@drpromodusinstitute.in
Paper was presented in S.C Gupta award in the NAIACP conference 2013 held at AIIMS, New Delhi on 24-26 Feb. 2013

8
 K. Promodu / Conquering New Frontiers in Clinical Psychology: The Sexual Medicine
regarding the same. There were 1019 rape cases in
the State during 2012 (Kerala State Crime Records
Bureau, 2012). This is much higher compared to
that of previous years (2009 - 568, 2010 - 634
and 2011 - 1,132). Thus the subject assumes vital
importance deserving informed debate.
Recent instance of repeated gang rape
resulting in fatality is the most alarming and a
disgrace to mankind. This kind of deviant sexual
behaviour is stemming out from suppressed sexual
feelings, mental aberrations, personality disorders
and inadequate value systems. Those who are
unable to satisfy their sexual needs in an appropriate
and responsible manner may turn to deviant or
FULPLQDO EHKDYLRXUV 7KH VFLHQWL¿F FRPPXQLW\
should analyze and decode the causative factors
behind these animal instincts in human beings and
put in place appropriate preventive measures.
Sexuality is one of the fundamental and
integral aspects of human beings, a dimension of
personality. Sexual behaviour is universal but varies
from person to person, country to country, between
different ages, genders and cultures with an array
of similarities and / or some surprising differences.
It is more personal than economic or political. The
thread of sexuality is woven densely into the fabric
of human existence. There are few people for
whom sex has not been important at some point of
time and many for whom it has played a dominant
part in their lives. Sex is a motive force leading two
people to intimate contact (Bancroft, 1989).
By virtue of evolution, humans sexuality
has achieved a role which is more than the act
of reproduction; in addition it has recreational
and relational functions. The way sex can bind a
couple and foster intimacy is the most positive non-
reproductive aspect of sexuality. While for many
species sexual behaviour is biologically controlled
and limited to the purpose of reproduction.
For the humans, it is not only physical but also
psychological or emotional. The risk of failure,
rejection, humiliation, exploitation etc. is a
major concern and often culminates in sexual
dysfunctions and related problems. Irresponsible
sexual behaviour leads to sexual violence, sexual
abuse, unwanted pregnancies, abortions, sexually
WUDQVPLWWHG LQIHFWLRQV PDULWDO FRQÀLFW GLYRUFHV
9
emotional and physical trauma etc. Many studies
have shown that sexual dysfunction and poor
quality of life are closely intertwined (Ventegodt,
1998; Thompson et al., 2011; Penhollow et al.,
2009; Elsenbruch et al., 2003).
Sexual dysfunction was previously considered
as a psychological condition or disorder. The Kinsey
Reports and Masters and Johnson’s studies tended
to isolate “performance anxiety” as the root cause
of most sexual disorders. Later, in the 1970s, Helen
Singer Kaplan focused on enhancing sexual desire
rather than sexual performance. Her biological
approach to sexuality, i.e., equating sexual desire
with physical appetite, was indeed helpful in sex
WKHUDS\+HUDSSURDFKZDVIXUWKHUMXVWL¿HGE\WKH
epidemiological studies during the 1980s. By the
1990s, the concept of human sexuality evolved as a
complex bio-psychosocial phenomenon.
6H[XDO KHDOWK LV GH¿QHG DV D VWDWH RI
physical, emotional, mental, and social wellbeing
related to sexuality. It is not merely an absence
RIGLVHDVHG\VIXQFWLRQRULQ¿UPLW\EXWUHTXLUHV
a positive and mutually respectful approach
to sexuality and sexual relationship (WHO,
2002). The term sexual dysfunction denotes the
various ways in which an individual is unable to
participate successfully or satisfactorily in the
sexual relationship. Psychological and somatic
processes are usually involved in the causation of
sexual dysfunction. It may be due to biological,
cultural, intra-psychic or interpersonal factors or
a combination of all these. Since the etiology of
sexual dysfunction is multi factorial, treatment
should also be addressed likewise. Thus, the role
of a multidisciplinary team of specialists becomes
more important and relevant in the effective
management of sexual dysfunction.
Epidemiological data shows that the
magnitude of sexual problems in our country is
alarmingly high (Varghese et al., 2012; Shanker et
al., 2013; Singh et al., 2009). People with sexual
problems are being exploited frighteningly. One
can see numerous quacks milking money out of
ignorance of the unsuspecting public. Marital
discord and divorce due to sexual problems are
steadily increasing as evidenced from the large
number of divorce petitions piling up at the
 K. Promodu / Conquering New Frontiers in Clinical Psychology: The Sexual Medicine
family courts. Common man is not aware of who
is the correct doctor to be consulted for their
sexual problems. This helps quacks to exploit
and endanger the sexual and marital health.
Surprisingly, many medical doctors are not
FRQ¿GHQWRUFRPSHWHQWHQRXJKWRGHDOZLWKVH[XDO
problems and shy away with a mere promise of
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TXDOL¿HGPHGLFDOSURIHVVLRQDOVZKRRQWKHLURZQ
practice sexual medicine in our country.
This is consensual opinion that no single
expert can deal with sexual problems adequately
DQGVFLHQWL¿FDOO\DVWKHVHDUHVWHPPLQJRXWIURP
multi factorial etiology. It strongly believed that
a multi disciplinary team is inevitable to arrive at
the correct diagnosis and effective management of
sexual problems. The team of specialists comprise
Andrologist cum Urologist, Gynecologist, Marital
Therapist, Physician, Diabetologist, Cardiologist,
Psychiatrist, Sonologist and Anesthesiologist
under the leadership of a Clinical Psychologist
cum Sex Therapist. All male patients with sexual
dysfunctions are being need to be evaluated
E\ D JHQHUDO PHGLFDO RI¿FHU DQGURORJLVW DQG
clinical psychologist; whereas all female patients
are need to be evaluated by the gynaecologist
and clinical psychologist. In case of any
marital discord, couple needs to be referred to
marital therapist who is a clinical psychologist
specialized in marital therapy. Depending on the
physical complaints, patients may be referred to
the physician, cardiologist or other specialists.
After the clinical evaluation, investigations and
discussions, team jointly arrive at the diagnosis.
7UHDWPHQW LV SODQQHG EDVHG RQ WKHVH ¿QGLQJV
In most of the cases a combination of different
modalities of treatment such as sex therapy,
cognitive behaviour therapy, marital therapy,
medicines, surgery etc. are integrated. It helps to
achieve the maximum and the best result. Total
12,718 new cases were listed in Dr Pramodu's
Institute of Sexual & Marital Health Pvt. Ltd,
Kochi, Kerala between 31st Jan 2006 to 3st Jan
2012. All were assessed clinically and treatment
was planned according to their needs.
These patients belong to various diagnostic
categories comprising of different age groups,
10
genders, marital status, socio economic
background, languages, cultures, hailing from
different parts of the country and a few foreigners.
Out of the 12,718 patients, 10,977 comprise of
9,605 (87.5%) men and 1,372 (12.5%) women
had sexual problems.
g. &RPPRQ3UREOHPV,GHQWL¿HG
Fig.
From a broader perspective common
problems found (Fig. 1) are sexual dysfunctions,
unconsummated marriages, infertility and marital
discord. The common sexual dysfunctions for
which men sought treatment are enlisted in table
1 which shows that among the 9605 cases, large
chunk of patients suffer from erectile dysfunction
(ED-63.10%) followed by premature ejaculation
(30.40%), male orgasmic dysfunction (3.27%),
sexual desire disorder (2.96%), sexual aversion
disorder (0.28%) and excessive sexual desire
(0.01%). A few patients are suffering from more
than one clinical conditions and hence coded on
more than one diagnostic category.
Table 1: Diagnostic Breakup - Male Sexual
Dysfunction :
Sexual dysfunctions Percentage
Erectile Dysfunction 63.10
Premature Ejaculation 30.40
Male Orgasmic Dysfunction 3.27
Male Sexual Desire Disorder 2.96
Male Sexual Aversion Disorder 0.28
Excessive Sexual Desire 0.01
(' KDV D VLJQL¿FDQW LPSDFW RQ WKH TXDOLW\
of life (QOL) of the sufferers, their partners and
families. Approximately 5-20% of men have
moderate to severe ED. PE also has negative
consequences such as personal and partner
GLVWUHVVIUXVWUDWLRQFRQÀLFWDQGRUWKHDYRLGDQFH
of sexual intimacy. The prevalence of acquired
PE is 20-30% and lifelong PE is 2-5% (Wespes et
 K. Promodu / Conquering New Frontiers in Clinical Psychology: The Sexual Medicine
al., 2006). Premature ejaculation (PE) can lead to Out of the 9605 men with sexual
erectile dysfunction (ED) and ED can lead to PE. dysfunctions, 7207 individuals had comorbid
Dual problem of PE and ED are the most daunting urological problems, either minor or major (Table
FKDOOHQJHVLQWKH¿HOGRIVH[RORJ\'HWHUPLQLQJWKH 3). In addition to the sexual dysfunction co morbid
cause and effect relationship between the two is of gynaecological problems were found among 280
great clinical importance for adequate treatment. females. Out of the 10,977 cases with sexual
Table 2: Diagnostic Breakup - Female Sexual Dysfunction : dysfunction 1,277 patients had some sort of major
Female Sexual dysfunctions Percentage or minor mental disorder. The presence of different
Vaginismus 59.06 FRPRUELGFRQGLWLRQVGH¿QLWHO\SRLQWVWRZDUGVWKH
Female Orgasmic Dysfunction 12.58 relevance of a multidisciplinary team approach in
Female Sexual Desire Disorder 11.83 the evaluation and management of these cases.
Female Sexual Arousal Disorder 6.93
As sex is a mystery, it is a subject of study
Dyspareunia 5.97
Female Sexual Aversion Disorder 3.52 when one thinks of the fact that life would be
Excessive Sexual Desire 0.11 unsuccessful without this most natural form of
Analysis on 1372 women (Table 2) shows instinct. Human sexual response involves both
that vaginismus (59.06%) is the most common mind and body, thus a persistent dualism exists in
sexual dysfunction among women for which the assessment and treatment of sexual problems.
treatment was sought followed by female That is why along with the pharmacological or
orgasmic dysfunction (12.58%), female sexual surgical treatments psychological interventions
desire disorder (11.83%), female sexual arousal like sex therapy and cognitive behaviour
disorder (6.93%), dyspareunia (5.97%) and female therapy are inevitable. Sex therapy is a form of
sexual aversion disorder (3.52%). Vaginismus treatment for sexual problems by modifying and
affects a woman’s ability to engage in any form of incorporating sexual experiences to alleviate or
penetrative sex leading to female factor infertility. cure the symptoms or disorders with the help of
These patients rarely cooperate for gynaecological psychological methods. Since each individual is
examinations. It is the most common cause of unique, one needs personalised treatment strategies
non - consummation of marriage due to female depending on the cause and severity of the problem.
factor. Prevalence of this disorder among clinical Fig. 2: Different Modalities of Treatment Used:
population ranges from 5 to 17% (Lahaie et al.,
2010). Female sexual desire disorder is another
problem that causes marked distress for the couple,
RIWHQOHDGVWRPDULWDOFRQÀLFWDQGDWWLPHVHQGXSLQ
separation or divorce. The Global Study of Sexual
Attitudes and Behaviours (Gingell et al., 2005)
found that 26% to 43% of women experienced low
sexual desire compared to 13% to 28% of men. All
cases were evaluated individually and screened for
any comorbid medical conditions.
Table 3: Comorbidity in Sexual Dysfunction Cases :
Fig. 2 shows the different treatment
Sexual No of No of
Dysfunction patients
Co-morbidity
Cases
% modalities used in the management of sexual
Male 9605 Urological Diseases 7207 75% dysfunctions. It was found that 30% of the cases
Female 1372 Gynaecological 280 20% were treated with medicines alone, 34% with
Problems a combination of medicine and psychological
All cases 10977 Other General 4937 45% intervention, 11% with sex therapy alone,
Medical Conditions 10% with CBT and 5% with surgery. In short
All cases 10977 Mental Disorders 1277 12% psychological intervention either alone or in

11
 K. Promodu / Conquering New Frontiers in Clinical Psychology: The Sexual Medicine
combination was used in 55% cases. There was
a drop out of 10%. Sexuality is experienced or
expressed in thoughts, fantasies, desires, beliefs,
attitudes, values, activities, practices, roles as
well as relationships and being interplay of both
biological and psychological factors, it has to be
treated likewise.
Fig. 3: Treatment Outcome :
The overall outcome of the treatment is shown
LQ¿JZKLFKUHYHDOVWKDWWKHRYHUDOOUHFRYHU\UDWH
is 80.79%. 54% had full recovery and 27% had
VLJQL¿FDQWV\PSWRPDWLFLPSURYHPHQW7KHSDWLHQWV
ZKRGLGQRWJHWDQ\VLJQL¿FDQWLPSURYHPHQWDQGWKH
GURSRXWVWRJHWKHUDFFRXQWVIRU7KHVH¿QGLQJV
not only demonstrate the relevance of psychological
intervention especially sex therapy but also
highlights the importance of a comprehensive
multidisciplinary model in the management of
human sexual problems and concerns.
CONCLUSION
Clinical Psychologists, both academicians
DQG SUDFWLWLRQHUV DOLNH ¿QG WKHPVHOYHV
FRQ¿QHG RU HQWDQJOHG LQ WKH WUDGLWLRQDO UROH RI
psychometricians, counsellors, psychotherapists
or teachers. Concerted efforts are required to come
out of this mindset and build up new frontiers in
Clinical psychology. The science of psychology
is merely a century old, yet, its scope and impact
have already expanded beyond imagination.
Clinical Psychologists must broaden their
horizon and be innovative to move out from the
cocoons of mental hospital, psychiatry set up
and work in a team believing in egalitarianism
to serve the needy public. Clinical Psychologists
have a crucial role in dealing with the problems
and challenges faced by mankind. The clinical
psychologists can join hands with different
12
specialists in the medical fraternity and conquer
newer domains, thereby expanding the horizon
and ambit of Psychology.
REFERENCES
Bancroft, J. (2009). Human Sexuality and its Problems (3rd Ed.)
Edinburgh: Churchil Livingston.
Elsenbruch,S., Hahn, S., Kowalsy, D., Offner, A.H.,
Schedlowski, M., Mann, K., & Janssen, O.E. (2003).
Quality of life, psychosocial well-being, and sexual
satisfaction in women with polycystic ovary syndrome.
Journal of Clinical Endocrinology & Metabolism.
88(12), 5801-5807.
Gingell, C., Laumann, E.O., Nicolosi, A., Glasser, D.B., Paik,
A., Moreira, E., & Wang, T. (2005). Sexual Problems
Among Women and Men Aged 40–80 years: Prevalence
DQG&RUUHODWHV,GHQWL¿HGLQWKH*OREDO6WXG\RI6H[XDO
Attitudes and Behaviours. International Journal of
Impotence Research 17(1), 39-57.
Kerala State Crime Records Bureau (2012). www.NHUDODpolice.
org/newsite/scrb.html
Lahaie, M.A., Boyer, S.C., Amsel, R., Khalifé, S., & Binik,Y.M.
(2010). Vaginismus: A Review of the Literature on
WKH &ODVVL¿FDWLRQ'LDJQRVLV (WLRORJ\ DQG 7UHDWPHQW
Women’s Health, 6 (5), 705-719.
Nanda, A. (2013). Reality and Rape. Orisa Post. Editorial, PNN.
Penhollow, T. M., Young, M., & Denny, G. (2009). Predictors of
quality of life, sexual intercourse, and sexual satisfaction
among active older adults. American Journal of Health
Education, 40 (1), 14-22.
Shanker, S. R. A., Phanikrishna, B., & Reddy, B.V. C. (2013).
Association between erectile dysfunction and coronary
artery disease and it’s severity. Indian Heart Journal, 65
(2), 180-186.
Singh, J.C., Tharyan, P., Kerkre, N.S., Singh, G., &
Gopalkrishnan, G. (2009). Prevalance and risk factors
for female sexual dysfunction in women attending a
medical clinic in south India. Journal of Postgraduate
Medicine, 55 (2), 113-120.
Thompson, W.K., Charo, L., Vahia, I.V., Allison, M., & Jeste,
D. V. (2011). Association between higher levels of
sexual function, activity, and satisfaction and self-rated
successful aging in older postmenopausal women. Journal
of American Geriatric Society, 59 (8), 1503-1508.
Varghese, K.M., Bansal, R., Kekre, A.N., & Jacob, K.S. (2012).
Sexual dysfunction among young married women in
southern India. International Urogynecology Journal,
23 (12), 1771-1774.
Ventegodt, S. (1998). Sex and the Quality of Life in Denmark.
Archives of Sexual Behaviour, 27(3), 295-307
Wespes, E., Amar, E., Eardley, I., Giuliano, F., Hatzichristou,
D., Hatzimouratidis, K., Montorsi, F., & Vardi, Y.
(2006). Guidelines on Male Sexual Dysfunction:
Erectile Dysfunction and Premature Ejaculation. Eur
Urol, 49 (5), 806-815.
World Health Organisation (2002). 'H¿QLQJ 6H[XDO +HDOWK
Report of a technical consultation on sexual health,
Geneva, 28-31.
Indian Journal of Clinical Psychology Copyright, 2013 Indian Association of
2013, Vol. 40, No. 1, 13-22 Clinical Psychologists (ISSN 0303-2582)
Research Article
Assessment of Neuropsychological Functions in Schizophrenia
Adarsh Kohli
ABSTRACT
&RJQLWLYHGH¿FLWVLQVFKL]RSKUHQLDKDYHEHHQREVHUYHGZLWKQHXURSV\FKRORJLFDOWHVWV The aim
RI WKH SUHVHQW VWXG\ ZDV WR DVVHVV QHXURSV\FKRORJLFDO SUR¿OH RI SDWLHQWV ZLWK VFKL]RSKUHQLD
3UHVHQW VWXG\ ZDV SODQQHG WR HYDOXDWH WKH QHXURSV\FKRORJLFDO SUR¿OH RI ,QGLDQ SDWLHQWV ZLWK
schizophrenia and determine its socio-clinical correlates. The sample consists of twenty
clinically stable outpatients with ICD-10 diagnosis of schizophrenia and equal number normal
controls matched for age, gender, education and handedness were studied using a battery of
neuropsychological tests. The tests consisted of verbal and performance intelligence tests, tests
for memory, perceptual motor skills, and Wisconsin Card Sorting Test (WCST). Results reveal on
WCST and perceptual-motor functions patients with schizophrenia did not showed impairments
FRPSDUDEOHWRKHDOWK\FRQWUROVEXWSDWLHQWJURXSSHUIRUPHGVLJQL¿FDQWO\SRRURQYHUEDOÀXHQF\
arithmetic, comprehension, spatial and abstract ability of intelligence, immediate recall, delayed
recall, new learning and recognition sub-tests of memory. Years of education was positively
FRUUHODWHGZLWKVFRUHVRQFRQFHSWXDOOHYHOUHVSRQVHRI:&67YHUEDOÀXHQF\YHUEDOTXRWLHQW
(and its sub-tests), performance quotient, immediate recall, and new learning. Memory improved
with stability of illness, whereas ability to maintain cognitive set deteriorated. With increasing
duration of illness social cognition and verbal ability (tested on comprehension and verbal
ÀXHQF\UHVSHFWLYHO\GHFOLQHG,QFUHDVHGGUXJGRVDJHZDVVLJQL¿FDQWO\FRUUHODWHGZLWKGHFOLQH
in recent memory and retention. The present study does not provide evidence for a localized
QHXURSV\FKRORJLFDOLPSDLUPHQWLQVFKL]RSKUHQLDEXWLWLVLQGLFDWLYHRIPRUHJHQHUDOL]HGGH¿FLWV
Absence of impairments in WCST and perceptual-motor skills does not agree with the results of
other studies using these tests.
.H\:RUGVSchizophrenia, Neuropsychology, Cognitive Functions, Executive Functions, Impairment.

INTRODUCTION YDULRXV QHXURSV\FKRORJLFDO GH¿FLWV LQ WKHVH

Schizophrenia is accompanied by impairments
in several neuropsychological domains, some more
GLVDEOLQJWKDQRWKHUV1HXURSV\FKRORJLFDOGH¿FLWV
have been seen to be more enduring (Cassens et
al., 1990; Goldberg et al., 1993) where impaired
performance on standardized neuropsychological
patients. Some authors had initially mentioned that
memory may remain intact in acute schizophrenia
although mnemonic impairments are common
in chronic cases (Cutting, 1995). Subsequently,
memory impairments and attention has been
reported and regarded as some of the major
tests is recognized as a core characteristic of
schizophrenia (Goldberg et al., 1991; Bilder et al.,
1992). The challenge we face in understanding the
nature of cognitive impairments in schizophrenia
is that, at least on the surface, individuals with this
LOOQHVV DSSHDU WR KDYH GH¿FLWV LQ D GLYHUVH DUUD\
of domains, such as working memory, language
function, executive function, episodic memory,
processing speed, attention, inhibition and sensory
processing (Mesholam-Gately et al., 2009; Forbes
et al., 2009). There is evidence for generalized
intellectual decline (Payne, 1973) along with
Professor, Clinical Psychology, Dept. of Psychiatry, PGIMER, Chandigarh
13
QHXURSV\FKRORJLFDO GH¿FLWV +LOO HW DO 
Additionally, it has been reported that memory
impairment is disproportionate to the general
intellectual decline (McKenna et al., 1990).
A commonly reported impairment in
schizophrenia is related to executive functions. A
recent study by Pradhan et al. (2008) compared
schizophrenic with healthy controls. They found
QHXURSV\FKRORJLFDOGH¿FLWVLQH[HFXWLYHIXQFWLRQV
SHUFHSWXRPRWRU DUHDV DQG PHPRU\ 'H¿FLWV LQ
learning and memory have also been noted in
schizophrenia (Bleuler, 1911; Kraepelin, 1919).
 Adarsh Kohli / Assessment of Neuropsychological Functions in Schizophrenia
Ornstein et al. (2008) used a battery of memory schizophrenia. Abnormalities of memory appear to
and executive tests and compared thirty patients be related to an increased liability to psychosis in
with chronic schizophrenia, 24 patients with general.
frontal or temporal brain damage and 30 healthy $V VKRZQ LQ OLWHUDWXUH WKH GH¿FLW SDWWHUQ
controls. Compared to brain damage and healthy shows wide variation, and the overall extent and
controls schizophrenia patients were rated as nature of neuropsychological impairments varies
KDYLQJ VLJQL¿FDQWO\ PRUH H[HFXWLYH IDLOXUHV WKDQ considerably. Such variations are likely to occur
memory failures. Neuropsychological research due to multiple reasons i.e. heterogeneity in the
LQ VFKL]RSKUHQLD VXJJHVWV GH¿FLWV LQ DFTXLVLWLRQ
and short term retention of information but not in
remembering information learned earlier (Gold et
al.,1992; Saykin et al., 1991). Data suggests that
the anatomical circuits responsible for memory
functions are impaired in schizophrenic patients.
'H¿FLWVLQVHYHUDOYHUEDOOHDUQLQJWDVNVKDYHDOVR
been noted in both patients who have received
temporal lobectomy for interactable epilepsy and
in patients with schizophrenia (Milner, 1971;
Gruzelier et al., 1988). Hill et al. (2001) compared
QHXURSV\FKRORJLFDO GH¿FLWV DPRQJ GLIIHUHQW
VXEW\SHVRIVFKL]RSKUHQLDDQGIRXQGGLIIXVHGH¿FLWV
with more severe impairments in learning and
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UHÀHFW ELODWHUDO IURQWDOWHPSRUDO G\VIXQFWLRQ
Reichenberg and Harvey (2007) present quantitative
evaluation of the literature demonstrating that the
most severe impairments are apparent in episodic
memory and executive control processes, evident
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The neuropsychological impairments potentially
represent genetic liability to the disorder;
impairments are evident in schizophrenia patients
even before the onset of psychotic symptoms,
as well as in the nonpsychotic relatives of
schizophrenia patients. McIntosh et al. (2005)
administered a neuropsychological test battery to
50 controls, 74 patients and 76 unaffected relatives.
Patients included those with schizophrenia and
from families affected by schizophrenia alone. In
results, current, verbal and premorbid IQ’s were
impaired in people with schizophrenia and in their
close relatives. Memory was impaired in all patient
and relative groups. Psychomotor performance
and performance IQ were impaired in patients
DORQH 7KLV VWXG\ ¿QGV HYLGHQFH WKDW LQWHOOHFWXDO
abnormalities are related to a genetic liability to
14
SDWLHQW JURXSV FOLQLFDO DQG PHGLFDWLRQ SUR¿OH
assessment at different stages of their illness, and
adopting different assessment tools and methods.
Assessment of neuropsychological
dysfunction in patients with schizophrenia is
important as these enduring cognitive impairments
can be responsible for the inability of such patients
to rehabilitate socially even when psychotic
symptoms are in remission. Also, characterization
RIFRJQLWLYHGH¿FLWVFRXOGEHRIFRQVLGHUDEOHYDOXH
LQ GH¿QLQJ WKH QHXURSV\FKRELRORJLFDO EDVLV RI
VFKL]RSKUHQLD1HXURSV\FKRORJLFDOGH¿FLWVDUHDOVR
linked to disability (Green, 1996); neurocognition
is necessary for optimal adaptation and accounts
for 20-50% of the variance in functional outcome
(Sabhesan & Parthasarthy, 2005). So keeping
in view optimal adaptation and rehabilitation it
LV QHFHVVDU\ WR VWXG\ QHXURFRJQLWLYH GH¿FLWV LQ
schizophrenia because even after remission if these
GH¿FLWVDUHQRWKDQGOHGZLWKFRJQLWLYHUHPHGLDWLRQ
social skills training and vocational rehabilitation
than it may not lead to adequate functional and
social recovery from the illness.
AIM AND OBJECTIVES
The aim of the study was the assessment
RI QHXURSV\FKRORJLFDO SUR¿OH RI SDWLHQWV ZLWK
VFKL]RSKUHQLDDQGWKHVSHFL¿FREMHFWLYHVZHUH
1. To study the pattern of neuropsychological
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various neuropsychological tests.
 7R FRPSDUH QHXURSV\FKRORJLFDO SUR¿OH RI
patients with schizophrenia and matched
healthy controls.
3. To determine, if any, socio-clinical correlates
of neuropsychological functioning in patients
with schizophrenia.
 Adarsh Kohli / Assessment of Neuropsychological Functions in Schizophrenia
MATERIAL AND METHODS
Sample: Twenty outpatients of schizophrenia
diagnosed according to ICD-10 criteria by a
consultant psychiatrist attending the Department
of Psychiatry, Postgraduate Institute of Medical
Education and Research, Chandigarh comprised
the study sample. The patients were judged to be
clinically stable (i.e. no increase in drug dosage
by more than 50% in the 3 months preceding the
assessment) and were in the age range of 20-55
years, of either gender, and had at least 10 years
of formal education. Co-morbid psychiatric illness,
substance abuse or presence of major physical
illness served as the exclusion criteria.
Twenty normal healthy controls matched
for age, education, gender and handedness were
recruited from volunteers from the staff members of
the institute for comparative purposes. The controls
were administered General Health Questionnaire-12
(Goldberg, 1988) for ensuring their health status.
A score of < 2 was deemed necessary for ensuring
absence of psychological problems.
Design: Cross-sectional assessment.
Instruments: Following tools were used
to measure different neuro-cognitive functions in
patients and normal.
1. Verbal Adult Intelligence Scale (VAIS;
Pershad et al., 1984): It consists of four
verbal subtests viz. information, digit span,
arithmetic and comprehension. Norms are
available for age, sex, and education for
the Indian population. Test retest reliability
ranged from 0.87 to 0.98, split-half reliability
ranged from 0.59 to 0.85 for four tests,
separately for males and females.
2. Bhatia Battery of Performance tests
of Intelligence (BSS; Murthy, 1965): It
consists of two tests - Koh’s Block Design
and Pass Along test measuring spatial,
abstract and practical ability respectively. It
is standardized on Indian population.
3. PGI Memory Scale (PGIMS; Pershad,
1977): It consists of ten subtests viz. remote
memory, recent memory, mental balance,
attention and concentration, delayed recall,
15
immediate recall, retention of similar pairs,
retention of dissimilar pairs, visual retention,
and recognition. Test retest reliability of
PGIMS ranged from 0.69 to 0.85.
4. Bender Visual Motor Gestalt test (BVMG;
Bender, 1938): It measure perceptual motor
skills and consists of eight geometrical
drawings to be copied on a plain sheet of
paper. Norms are available for the Indian
population (Pershad, 1984).
5. Set test (Issac,1972): It measures the verbal
ÀXHQF\ PHPRU\ DQG PHQWDO HI¿FLHQF\ ,W
consists of four categories (names of animals,
colors, fruits and, cities) to be recalled within
2 minutes each. This test has been widely
used in the Indian population.
6. Wisconsin Card Sorting Test (WCST;
Heaton, 1981): The Wisconsin Card Sorting
Test (WCST) was administered as a test of
executive functions.
Procedure:
Both the study groups were assessed on the
battery of neuropsychological tests outlined above.
It was a cross-sectional assessment carried out over
1 to 2 sessions. All these tests were administered
and scored by trained clinical psychologists.
Statistical Analysis:
Descriptive statistics in the form of mean,
S.D., and frequency (%) were computed for all
variables. The two groups were subjected to
parametric (t-test) tests for continuous variables.
Spearman’s Rank Order Correlations were
calculated to assess the socio-clinical correlates
RI QHXURSV\FKRORJLFDO SUR¿OH RI SDWLHQWV ZLWK
schizophrenia.
RESULTS
Patients
Of the 20 patients with schizophrenia, 55%
were males and 60% were single. As regards
occupational status, 40% were unemployed, 25%
were housewives, 10% were students, and 25%
from other occupational background. 55% were
Hindus, 85% belonged to nuclear families and
80% were from rural background. All patients had
 Adarsh Kohli / Assessment of Neuropsychological Functions in Schizophrenia
completed at least 10 educational years and were Table 2 shows comparative scores obtained
right handed. on the Set test for both groups. Patients with
:LWK UHJDUG WR WKH FOLQLFDO SUR¿OH WKH VFKL]RSKUHQLD REWDLQHG VLJQL¿FDQWO\ ORZHU VFRUHV
mean duration of illness was 114.35 (SD= 67.08, on all variables.
Range=23-268) months. The mean stability of Table 3 : Mean, SD and t values of Verbal Adult
illness was 17.50 (SD= 15.42, Range= 3-48) months. Intelligence Scale and Bhatia Battery Short
The drug dosage ranged from 150-1000 mg/day, Scale
with a mean dosage of 470 mg of chlorpromazine Normal
Subtests Schizophrenics t -values
equivalents per day. Controls
Information 106.00±21.32 101.70±25.09 0.58
Normal Controls Digit span 104.65±19.20 101.25±21.91 0.52
Twenty normal controls matched (pair Arithmetic 97.25±14.32 82.60±22.18 2.48*
wise) for age, sex, education and handedness were Comprehension 112.50±11.90 96.20±22.04 2.81**
included in the study. 30% of the subjects were Verbal Quotient 106.65±24.69 95.55±18.98 2.06*
single and 70% were married. 25% were students, Koh’s Block
9.00±3.31 6.30±2.79 2.79**
5% were housewives and 70% belonged to other Design
occupational categories; none were unemployed. Pass Along 9.20±2.82 8.90±3.01 0.33
85% were Hindus and 15% were Sikhs. 75% of them Performance
101.90±15.50 93.75 ±15.81 1.65*
quotient
were from nuclear, 15% from joint, and 10% from
other family types. All were from urban background. *p<0.05, ** p<0.01
Table 3 shows the comparative scores for
Table 1 : Mean, SD and t-values of scores on
Verbal Adult Intelligence Scale (VAIS) and Bhatia
Wisconsin Card Sorting Test
Short Scale (BSS). The scores of patients with
Normal Schizo- t-
Variables (WCST)
controls phrenics values VFKL]RSKUHQLD ZHUH VLJQL¿FDQWO\ ORZHU IRU YHUEDO
Trials Administered 125.40±6.87 125.05±9.25 0.14 and performance tests of intelligence.
Total number correct 73.30±15.66 67.20±12.34 1.37 Table 4 : Mean, SD and t-values of scores on
Perservative responses 41.30±13.70 45.65±12.67 1.04 PGI Memory Scale
Perservative errors 31.85±16.38 35.55±18.57 0.67
Normal
Percent perservative error 25.20±12.61 28.00±14.05 0.66 Subtests Schizophrenics t - values
controls
Non-perservative error 20.00±8.88 22.20±11.05 0.69 Remote
5.80±0.41 5.40±1.05 1.59
Conceptual level response 56.05±19.30 51.05±17.76 0.85 memory
No. of categories completed 3.55±1.61 3.25±1.68 0.58 Recent memory 4.95 ±2.24 4.75±0.72 1.19
1NE=HOP=GAJBKNłNOP?=PACKNU 2.75±26.37 35.65±37.33 1.26 Mental balance 7.85 ±1.09 6.55±2.14 2.42*
$OOWYDOXHVDUHVWDWLVWLFDOO\LQVLJQL¿FDQW Attention and
10.15±2.03 9.70±2.54 0.62
concentration
Table 1 Show comparative scores obtained Delayed recall 9.10±1.33 8.15±1.50 2.12*
on WCST for both groups. Both groups were Immediate
8.40±2.04 6.75±2.47 2.31*
FRPSDUDEOHDVµW¶YDOXHLVQRWVLJQL¿FDQWLQDQ\RI recall
the parameter of WCST. Retention for
4.09±0.31 4.6±8.21 1.53
similar pairs
Table 2 : Mean SD and t-values of categories of
Retention for
Set Test 13.9±1.41 10.65±3.88 3.52**
dissimilar pairs
Variables Normal Schizophrenic t -values Visual retention 11.60±1.70 10.60±3.19 1.24
Animals 17.60± 3.73 14.05±4.42 2.73** Recognition 9.5±0.90 8.15±2.43 2.33*
Colours 16.25±5.47 12.70±4.30 2.28* Percentile rank 53.30±8.51 42.85±13.85 2.88**
Fruits 13.85±4.52 11.25±2.59 2.23* * p<0.05; ** p<0.01
Cities 23.20±7.16 18.65±6.64 2.08*
Table 4 shows the comparative scores for
*p<0.05, ** p<0.01 both the groups on memory testing (PGIMS).

16
 Adarsh Kohli / Assessment of Neuropsychological Functions in Schizophrenia
6LJQL¿FDQWO\ ORZHU VFRUHV ZHUH REWDLQHG IRU It was seen that in WCST, there was positive
schizophrenia on all the components of PGI correlation between stability of illness and inability
memory scale. to maintain cognitive set. Duration of illness was
negatively correlated with verbal quotient of
7DEOH6LJQL¿FDQWUDQNRUGHUFRUUHODWLRQV
VAIS. Recent memory was positively correlated
between various neuropsychological and socio-
with stability of illness and recent memory and
clinical of schizophrenics new learning were impaired with increase of drug
Neuropsychological Years of Age Dura- Duration Avg. dosage. Errors on BVMG were also positively
variables education tion illness stability drug
dose correlated with dose increase.
WCST DISCUSSION
- Conceptual level .47* - - - - The present study evaluated the
response
- Trials to Ist category -.48* - - - - neuropsychological functioning of patients with an
- Failure -maintain set LOOQHVVRIVFKL]RSKUHQLD,Q¿QGLQJVSHUIRUPDQFH
- - - .55* - on various individual cognitive tasks rather than
Set test summary scores is reported and comparison is
- Animals .50* - -.66** - - made with normal matched controls. As patients
VAIS ZLWK VFKL]RSKUHQLD KDYH GH¿FLWV DFURVV D ODUJH
- Information .56* - - - -
- Arithmetic .53* - - - -
number of neurocognitive domains (Green, 1996)
- Comprehension .58* - -.47* - - therefore, performance within various tests was
- VQ .59** - -.46* - - examined.
BBS Intelligence (IQ): Examining the verbal
- PQ .56* - - - -
quotient and scores on its components, the patient
PGIMS group was found to be impaired on arithmetic,
- Recent memory - - - .51* -.46*
- Retention for similar - - - - -.48* FRPSUHKHQVLRQ DQG ZRUG ÀXHQF\ WHVWV 7DEOHV 
pairs 3) where maximum impairment was in the sub-
- Delayed recall - .50* - - - test of comprehension which is a measure of
- Immediate recall .55* - - - -
- Retention of .58* - - - - social cognition. Impairment on tests of spatial
dissimilar pairs DQGDEVWUDFWDELOLW\%66ZDVDJDLQVLJQL¿FDQWO\
- Percentile Rank .55* - - - - more common in the patient group pointing to a
BVMG .52* generalized intellectual decline; similar to that
* p<0.05; **p<0.01 reported by McIntosh et al. (2005). In a Meta
analytical study Mario et al. (2012) evaluated
Table 5 shows the rank order correlations general IQ measures (102 works, 8,416 total cases).
between neuropsychological and socio-clinical They found that 75 percent of the patient population
variables in patients with schizophrenia. On WCST, had intellectual impairment in comparison to
years of education was positively correlated controls.The data concerning the premorbid IQ,
with conceptual level of response and negatively are in general measured by NART or WRAT or
FRUUHODWHG ZLWK WULDOV DGPLQLVWHUHG IRU ¿UVW XVLQJ VSHFL¿F VXEWHVWV RI WKH :$,6 ZKLFK DUH
FDWHJRU\,Q6HWWHVWYHUEDOÀXHQF\UHFDOORIQDPH considered stable over-time. These data are based
of animals was positively correlated with years of on 48 works for a total number of 3,568 cases
education and negatively correlated with duration DQG VKRZ DQ (6 í > @ ,2 = 70%,
of illness. Similarly scores on VAIS and BSS were PS=65 %. The hypothesis based on the premorbid
positively correlated with education. On memory, IQ, that some cognitive discrepancies are already
new learning (retention of dissimilar pairs) was present in the patients population years ahead of
positively correlated with years of education, and an explicit expression of the clinical features of
delayed recall was positively correlated with age. WKLVGLVHDVHPLJKWEHFRQ¿UPHGE\WKHVHUHVXOWV

17
 Adarsh Kohli / Assessment of Neuropsychological Functions in Schizophrenia
at least in 2 cases out of every 3. Michel et al.
(2013) examined schizophrenic’s performance
on all WAIS-IV subtests, index and general
intelligence scores relative to healthy comparison
VXEMHFWV$QDO\VHVUHYHDOHGVLJQL¿FDQWLPSDLUPHQW
on several tasks, including the new Cancellation
subtest and the Verbal Comprehension. At the
index score level, group differences in Processing
6SHHGZHUHVLJQL¿FDQWO\ODUJHUWKDQWKRVHREVHUYHG
in all other cognitive domains. Impairments were
also observed in Working Memory amid relatively
preserved performance in Verbal Comprehension,
WKHUHE\ FRQ¿UPLQJ WKH SDWWHUQ RI LPSDLUPHQW
LGHQWL¿HG XVLQJ WKH :$,6,,, $ERYH 0HWD
DQDO\WLFDOVWXGLHVFOHDUO\VXSSRUWFXUUHQW¿QGLQJV
7KH ¿QGLQJV RI LPSDLUPHQW LQ YHUEDO DQG
spatial components of IQ are in keeping with
SUHYLRXV VWXGLHV RQ ¿UVW HSLVRGH DQG FKURQLF
patients with schizophrenia (Hoff & Weineke,
DO  VXJJHVWHG WKDW WKH PHPRU\ GH¿FLWV
shown in patients with schizophrenia are primarily
FDXVHGE\GH¿FLWVLQHQFRGLQJDQGUHWULHYDOUDWKHU
WKDQ VWRUDJH $OVR LQ SUHVHQW VWXG\ GH¿FLWV DUH
observable at encoding, acquisition, and retrieval
level where mental balance is a subtest to measure
working memory which is known to be an encoding
mechanism, immediate and delayed recall subtests
measure acquisition of information at verbal level
and visual recognition subtest of PGIMS is a
PHDVXUHRIUHWULHYDOIXQFWLRQV6RFXUUHQW¿QGLQJV
clearly demonstrate that schizophrenia patients
KDYHGH¿FLWVDWHQFRGLQJDFTXLVLWLRQDQGUHWULHYDO
levels. Findings by Deanna and Alan (2012)
suggest that there may be a common mechanism
GULYLQJ GH¿FLWV LQ PHPRU\ GRPDLQV ZKLFK LV
impairment in the ability to actively represent
goal information in working memory to guide
behaviour, a function refer to as proactive control.
6XFKGH¿FLWVLQSURDFWLYHZRUNLQJPHPRU\FRQWURO
0RKDPHGHWDO:RUGÀXHQF\ZDV
maximally impaired in the category for animals
EHFDXVHRIUHFDOOGLI¿FXOW\
Memory: In present study patients showed
VLJQL¿FDQW PHPRU\ GH¿FLWV LQ PHQWDO EDODQFH
immediate recall, delayed recall, new learning for
GLVVLPLODUSDLUVDQGYLVXDOUHFRJQLWLRQ6LJQL¿FDQW
differences were also observed in overall memory
percentile scores (Table 4). Numerous studies have
GHPRQVWUDWHGWKDWPHPRU\GH¿FLWVDUHFRUHIHDWXUHV
of schizophrenia. The evidence is so clear that the
National institute of Mental Health’s MATRICS
(Measurement and treatment research to improve
UHÀHFW LPSDLUPHQWV LQ GRUVRODWHUDO SUHIURQWDO
cortex, its interactions with other brain regions,
such as parietal cortex, thalamus and striatum,
DQG WKH LQÀXHQFH RI QHXURWUDQVPLWWHU V\VWHPV
such as dopamine, GABA and glutamate. Mario
et al. (2012) did a meta-analysis of the measures
of memory functioning, where the comparison
between 2,066 patients with schizophrenia and
 QRUPDO VXEMHFWV SURGXFHV DQ (6 í
[-1.44, -1.01] with an I2 = 86% and PS = 81%. These
UHVXOWVGHPRQVWUDWHWKDWWKHUHLVDVLJQL¿FDQWGHFOLQH
in memory functioning among the patients with
VFKL]RSKUHQLD FRQ¿UPHG E\ WKH KLJK SUREDELOLW\
cognition in schizophrenia) group included
PHPRU\GH¿FLWDPRQJWKHVHSDUDEOHIXQGDPHQWDO
GLPHQVLRQV RI FRJQLWLYH GH¿FLW LQ VFKL]RSKUHQLD
(Marder & Fenton, 2004). In the neuro-cognitive
memory domain, although memory is globally
described as impaired in the literature, but results
are heterogeneous probably because of the different
aspects or types of memory that can be measured
and because of the great number of different tasks
used. The differences were particularly large for
verbal learning, visual recognition memory, and a
measure of spatial working memory manipulation
(Verity et al., 2010). Findings of the present study
are also in line with above literature. Paulsen et
18
 WR ¿QG D SDWLHQW ZLWK PHPRU\ LPSDLUPHQW
YHUVXVDRISUREDELOLW\WR¿QGDSDWLHQWZLWK
scores similar to those of a normal case. They were
of the view that irrespective of the heterogeneity of
WHVWVWKHVH¿QGLQJVDUHWUXHDQGPD\EHUHSOLFDWHG
ZLWKVSHFL¿FVXEWHVWVRIGLIIHUHQWPHPRU\GRPDLQV
The meta-analysis by Aleman et al. (1999) indicates
memory impairment in schizophrenia to be wide
ranging and consistent across task variables, such
as level of retrieval support (free recall, cued
recall, or recognition), stimulus type (verbal versus
nonverbal), and retention interval (immediate
versus delayed). The extent of the memory
impairment may appear to be in accordance with
 Adarsh Kohli / Assessment of Neuropsychological Functions in Schizophrenia
a pattern of generalized dysfunction rather than RI GH¿FLW LQ DOO DELOLW\ GRPDLQV DV PHDVXUHG E\
D GLIIHUHQWLDO GH¿FLW %ODQFKDUG  1HDOH 
Although, the battery of tests used in this study
were different, yet it was possible to replicate the
¿QGLQJV LQ RWKHU VWXGLHV WKDW GH¿FLWV LQ PHPRU\
DQG OHDUQLQJ DUH WKH PDMRU VHOHFWLYH GH¿FLWV VHHQ
over and above general decline (Hoff & Weineke,
1998; Mohamed et al., 1999).
Perceptual-Motor Dysfunction: Tests of
perceptual-motor functions did not show any
VLJQL¿FDQW GLIIHUHQFHV FRQWUDU\ WR D SUHYLRXV VWXG\
that had shown evidence of impaired perceptual-
PRWRU IXQFWLRQLQJ LQ ERWK ¿UVW HSLVRGH DQG FKURQLF
patients with schizophrenia (Hoff & Weineke, 1998).
Previous neuropsychological studies have
repeatedly attempted to localize brain lesions
in schizophrenia based on performance on
standard clinical tests. Since the WCST assesses
YDULRXVIXQFWLRQVLWLVGLI¿FXOWWRGLIIHUHQWLDWHLWV
part in working memory from problem-solving
capacity or other executive functions. Therefore,
it is not surprising that patients with schizophrenia
may or may not perform poorly on the WCST.
Several studies have demonstrated impairments
of executive functioning in schizophrenia but
with different indices of measurement not WCST.
Performance on WCST is not localized to single
brain region but several brain regions in addition
to the prefrontal cortex were shown to affect
performance on the WCST. The disturbances in
prefrontal areas that were demonstrated may be a
QHFHVVDU\ EXW QRW VXI¿FLHQW FRQGLWLRQ IRU D SRRU
WCST performance (Nestler et al., 2002; Ahmed
standardized tests. However, the data generally
fails to support any model of localization (Cohen
et al., 2007), and instead supports generalized
impairment (Blanchard & Neale, 1994; Mohamed
et al., 1999). 7KHSUHVHQWVWXG\DOVRIDLOHGWR¿QG
HYLGHQFHIRUDVSHFL¿FORFDOL]HGLPSDLUPHQW
Wisconsin Card Sorting Test (WCST):
%HIRUHFRPLQJRQWRWKHVSHFL¿F¿QGLQJVLQSDWLHQWV
with schizophrenia, it shall be pertinent to discuss
WKH¿QGLQJVRQFRPSDULQJWKHGLVHDVHJURXSZLWK
the healthy normal controls. Our study showed that
both the groups were comparable on all variables
of the WCST. This can be interpreted in the
following ways i.e., [a] patients with schizophrenia
are not demonstrating any cognitive impairment
RQ:&67RU>E@GH¿FLWVDUHPRUHJHQHUDOL]HGWKDQ
VSHFL¿F >F@ /RFDOL]DWLRQ LQVWUXFWLRQV GLIIHUHQFHV
DUHUHVSRQVLEOHIRUQRQVLJQL¿FDQWSHUIRUPDQFH
The WCST is one of the most widely used
psychological tool to assess executive functioning
such as mental set shifting, problem-solving,
decision making, inhibitory control and working
memory. WCST performance was consistently
found to be lower in patients with schizophrenia.
This is also true in our study but differences are not
XSWRWKHVLJQL¿FDQFHOHYHO+RZHYHU:&67GRHV
QRW VHHP WR EH VSHFL¿F WR WKLV GLVRUGHU EHFDXVH
schizophrenia is characterized by a broad base
of cognitive impairment, with varying degrees
19
HWDO7KH¿QGLQJVRQ:&67VXJJHVWWKDW
there may be underlying frontal lobe dysfunction
in schizophrenia, as mentioned in other studies
(Martino et al., 2007). However, as pointed out
earlier, WCST, though indicative of, is not a direct
measure of frontal lobe dysfunction and other tests
DUHQHHGHGWRVXSSOHPHQWWKH¿QGLQJVVRREWDLQHG
Further, WCST is just one of the various tests
available for testing the executive functions of
an individual. Also, localization of the structures
VXEVHUYLQJ :&67 KDV EHHQ GLI¿FXOW DV LW PD\
not be a “pure” frontal lobe function test (Moore
& Gallagher, 2003). Goldberg et al. (1987) found
that the performance of patients with chronic
schizophrenia improved on the WCST when
they received explicit card-by-card instructions.
However, performance dropped to baseline levels
when the instructions were withdrawn. The
authors concluded that patients with schizophrenia
were unable to learn the WCST, suggesting
XQUHPHGLDEOHGH¿FLWVWKDWZHUHSUREDEO\OLQNHGWR
a prefrontal dysfunction. They proposed that the
patient’s failure did not result from not knowing
but from not doing; in other words, the necessary
information was received but was not used to
change card sorting behaviour. The patients were
able to learn to perform other, non-prefrontal
WDVNV VXJJHVWLQJ WKDW WKH SHUIRUPDQFH GH¿FLW
on the WCST was not due to inattention or lack
of effort (Raffard et al., 2009). So, things are not
 Adarsh Kohli / Assessment of Neuropsychological Functions in Schizophrenia
clear whether WCST performance of patients with
an illness of schizophrenia is due to unlocalized
EXWJHQHUDOL]HGGH¿FLWVDQGRUGLI¿FXOW\LQJLYLQJ
instructions. Whether WCST can serve as a
potential differentiation tool aiding diagnosis was
not evoked in the literature.
YHUEDOÀXHQF\LQGLFDWLQJWKDWDORQJHUGXUDWLRQRI
illness leads to impairments in the social component
of intelligence. It was also found that duration of
illness negatively affected the verbal quotient of
patients, indicating that, despite clinical stability,
the pathological process tends to persist with
9HUEDO ÀXHQF\ XVLQJ µVHW WHVW¶ ZDV
VLJQL¿FDQWO\ LPSDLUHG WRR +HQFH LW PD\ EH
surmised that the patient group did have underlying
frontal lobe dysfunction of some degree.
Correlates:
Various variables of different neuro-
cognitive domains were correlated with years of
education, age, duration of illness, duration of
stability of illness and drug doses. Education was
found to facilitate performance on various neuro-
cognitive tasks. Performance on conceptual level
responses in WCST was positively correlated
with number of years of education. Also, trials
some aspects of the patients’ neuropsychological
functioning.
Duration of stability of illness was positively
correlated with inability to maintain cognitive set;
UHDVRQV IRU WKLV ¿QGLQJ DUH XQFOHDU 7KH SRVLWLYH
correlation of recent memory with duration of
stability of illness indicates that cognitive stability
(for the memory process) can set in along with the
clinical stability.
With increased drug dosages, there was a
decline in recent memory and retention process.
This is in keeping with evidence that antipsychotic
PHGLFDWLRQWHQGVWRQHJDWLYHO\LQÀXHQFHFRJQLWLRQ
DGPLQLVWHUHGIRU¿UVWFDWHJRU\RQ:&67UHGXFHG (Mohamed et al., 1999; Bilder et al., 2000).
as number of years of education increased. Summary and Conclusions:
More number of years of schooling is associated 7KH SUHVHQW VWXG\ IDLOV WR ¿QG HYLGHQFH
with ‘higher ability’ leading onto better initial for localized neuropsychological impairment in
conceptualization and grasp into the correct sorting patients with chronic and stable schizophrenia.
strategy. IQ and memory sub-tests of verbal The impairments do not appear to be prominent
ÀXHQF\YHUEDOTXRWLHQWRQLQIRUPDWLRQDULWKPHWLF as reported in the West, especially on WCST
comprehension, performance quotient and recall, and perceptual-motor skills. There was also no
and new learning were positively correlated with VSHFL¿F SDWWHUQ HYLGHQFHG LQ WHUPV RI VRFLR
years of education on similar grounds (Moore clinical correlates with neuropsychological tests.
& Gallagher, 2003). It is an established fact that However, there was evidence of certain areas of
education facilitates performance in cognitive tasks neuropsychological functions being correlated
and it is positively correlated with intelligence and with socio-clinical factors as shown to some
memory functioning. extent in previous research (Mohamed et al.,
Age correlated positively with delayed recall; 1999; Moore & Gallagher, 2003). Findings clearly
reasons for this association being unclear. In a meta- demonstrated impairments in intelligence, memory
analytic study Aleman et al. (1999) found that the DQGYHUEDOOHDUQLQJZKLFKVXJJHVWVWKDWGH¿FLWVLQ
magnitude of memory impairment was not affected VFKL]RSKUHQLD DUH PRUH JHQHUDOL]HG WKDQ VSHFL¿F
by age, duration of illness, medication, patient or/ localized.
status, severity of psychopathology, or positive There are certain strengths of the study
symptoms. Negative symptoms showed a small viz. (a) a clinically stable patient population was
EXW VLJQL¿FDQW UHODWLRQ ZLWK PHPRU\ LPSDLUPHQW studied which aimed at maximizing measurement
Harvey et al. (1995) studied the geriatric chronic of trait-like neuropsychological characteristics
schizophrenics on memory and correlated them to and minimizing transient state-like effects
temporal or frontal regions of the cerebral cortex. associated with acute exacerbations and the
Duration of illness was negatively related associated treatment (Moore & Gallagher, 2003)
to measures of social cognition (comprehension, (b) reasonably comprehensive neuropsychological

20
 Adarsh Kohli / Assessment of Neuropsychological Functions in Schizophrenia
evaluation was carried out, and (c) demographic
characteristics (age, sex, education & handedness)
known to confound or effect the neuropsychological
SUR¿OH ZHUH FRQWUROOHG IRU +RZHYHU WKHVH
¿QGLQJV QHHG WR EH LQWHUSUHWHG LQ WKH OLJKW RI
psychometric limitations of currently available
neuropsychological measures. This is especially
relevant to the tests used for assessing executive
IXQFWLRQV ZKLFK E\ GH¿QLWLRQ DUH UHODWLYHO\
complex, open to problems of interpretation and
depend on a high degree of subject compliance,
ZKLFKPDNHVWKHPGLI¿FXOWWRXVHLQSDWLHQWVZLWK
schizophrenia. Moreover, the factor of differential
discriminating power of the various tasks further
limits the interpretability of neuropsychological
functions in patients with schizophrenia. Certain
other limitations (small sample size, confounding
effects of neuroleptics and anti cholinergic
medications, culture fairness of tests used) need to
be taken into consideration while interpreting the
results.
We can conclude by suggesting a need
for further in-depth studies from India on the
QHXURSV\FKRORJLFDO SUR¿OH RI SDWLHQWV ZLWK ERWK
¿UVWHSLVRGH DQG FKURQLF VFKL]RSKUHQLD XVLQJ
tests that are culture-free. This should lead onto
generation of data that can be then appropriately
utilized not only for understanding this intriguing
yet devastating illness, but also for formulating
a more comprehensive management for patients
suffering from schizophrenia.
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Indian Journal of Clinical Psychology Copyright, 2013 Indian Association of
2013, Vol. 40, No. 1, 23-28 Clinical Psychologists (ISSN 0303-2582)

Research Article
Perceived Social Support among the Family Members of
Mentally Ill Patients
Sampa Sinha1, Masroor Jahan2 and A.N. Verma3
ABSTRACT
The present study has applied caregivers’ need based approach that aimed to assess and
understand their perceived social support and also to know and compare the effect of
different ‘course of illness’ on the perceived support of their relatives. Present study aimed
to assess and compare the effect of different ‘course of illness’ of the patient on the perceived
social support of their relatives who were taking care of them. Data was collected at Out
Patient Department of Ranchi Institute of Neuropsychiatry & Allied Sciences (RINPAS),
Ranchi, Jharkhand, India. Sample consisted of 30 caregivers of bipolar affective disorder
(currently mania) patients and 30 caregivers of schizophrenic patients. Social Support
Questionnaire Short version (SSQ- short version) was administered to assess perceived
social support. Group comparison was done using t-test. Majority of the caregivers in both
groups perceived ‘poor’ social network. Caregivers of manic and schizophrenic patients
face more or less similar problem in perceiving social support (number of social support
and satisfaction with social support). Findings of the present study suggest that perception
of social support network does not necessarily determine the level of satisfaction from it.
Perceived social support of caregivers of schizophrenic (continuous course) and manic
(episodic course) patients is more or less similar. Level of satisfaction is not necessarily
associated with perception of social network.
.H\ZRUGVCaregiving, Perceived Social Network, Caregiver’s Satisfaction, Schizophrenia

INTRODUCTION condition and empower them to lead stable

The implementation of community
based mental health program and family based
rehabilitation of the psychiatrically ill patient
have sensitized the family to take long term care
of their patient at home. It is well-established
fact that long standing caregiving burden and
feelings of distress constantly endanger the
family members’ mental health, physical health
status and sense of well being condition. Previous
studies suggested that caregivers of mentally
ill patient were ‘at risk’ regarding their mental
health and even physical health condition as they
felt socially isolated and stigmatized (Greenberg
et al., 1992; Bradley et al., 2003). Considering
the caregivers’ health related vulnerability as
well as risk factors, the researchers are nowadays
emphasizing the need to identify and study in
details about the positive stimulus or factors i.e.
psychosocial and natural resources which can
further help to improve their day to day living
family life instead of caregiving responsibilities.
Literature suggests that the social support system
is considered as one of the major natural social
resources for the family member or caregiver to
directly reduce their burden (Dyck et al., 1999)
and work as a buffer against stress (Caplan,
1974; Brown & Harris, 1978). One recent study
reported that the perceived social support and
sense of satisfaction with it is consistently linked
to positive mental health whereas, the received
social support as well as social integration are
not (Uchino, 2009). Caregivers of mentally
ill patients, who perceived a lack of social
support for their caregiving activities, were
found more distressed by care giving tasks.
Chakrabarti and Gill (2002) suggested in a study
with caregivers of bipolar affective disorder
patients that the positive communication and
increased social involvement, has been found
to increase a family’s sense of satisfaction,

1. Psychiatric Social Worker, IHBAS, Dilsad Garden, Shahdara, New Delhi, 2. Additional Professor, Dept. of
Clinical Psychology 3. Associate Professor (Rtd.) Dept. of Psychiatric Social Worker, RINPAS, Kanke, Ranchi

23
 Sampa Sinha / Perceived Social Support among the Family Members of Mentally Ill Patients
sense of competence and produce better
functioning for patient. Dyck et al., (1999)
studied the availability of social network and
degree of satisfaction with the perceived social
support of the caregivers of schizophrenia
patients in relation to their burden and health
condition. The result indicated that increased
tangible social support predicted lower level of
caregiving strain and increased satisfaction with
social support predicted better physical health,
and mental health status among caregivers’ of
the patients. The relational regulation theory
hypothesizes that the ordinary conversations and
shared activities among close connected people
provide good support, reduce stress and enhance
positive mental health status and the largest part
of perceived social support is relational in nature
(Lakey, 2010; Lakey & Orehek, 2011). Silva
and Silva (2001) conducted study on relatives
of schizophrenia patients and suggested that
joint family must be encouraged to take and
divide caregiving responsibilities of a mentally
ill patient; as primary caregiver would feel
less-burden if they will get support from other
family members. Cultural conceptions of mental
disorders have harmful consequences for both
the family members and patients, for example,
by perceiving existent and non-existent barriers
as a major obstacle in help seeking behaviour
(Link et al., 1999). Perlick et al. (2007) in a study
with caregivers of people with bipolar disorder
reported that caregivers’ perception of stigma has
been found to be inversely associated with social
support and positively associated with their poor
mental health condition. Caregivers of patients
of schizophrenia and bipolar affective disorder
face similar levels of burden and often do not
seek social support as a coping method to deal
with it (Chadda et al., 2007). Recently needs of
the family members of schizophrenia and major
affective disorders are of interest to mental
health professionals because both the illnesses
are considered as major illnesses and chronic in
nature and their relatives’ sense of well being. In
some studies authors noted that bipolar illness is
an episodic, cyclical illness, so the relationship
between the distressful experience of family
24
members, their adaptability, perception of social
support and the patient’s clinical status overtime
may differ from that observed in schizophrenia
patient and at different phases of the patient’s
illness (Fadden et al., 1987; Kuruvilla, 1995;
Schene et al., 1998). Though some studies
suggest burden, coping and other elements of
the caregiving experience among the caregivers’
of bipolar affective disorder are no different
from caregivers’ of schizophrenia (Nehra et al.,
2005).
In India very few studies have focused
and assessed the social support of the caregivers
who are taking care of schizophrenia or bipolar
affective disorder people. Hence, present study
was planned to assess the family members
perceived social support who are taking care of
severe mentally ill (manic and schizophrenic)
patients at home. This study was also intended to
know and compare the effect of different ‘course
of illness’ of the patient on the perceived social
support of their relatives, who were taking care
of them.
Based on review of literature it was
hypothesized that perceived social support of
the family members’ of schizophrenia or bipolar
affective disorder (mania) patients will be
SRRU DQG WKHUH ZLOO EH QR VLJQL¿FDQW HIIHFW RI
the ‘course of illness’ on the family members’
perceived social support.
METHOD AND MATERIALS
This is a cross-sectional study using two
independent-group design.
Sample :
Study was conducted at out-patient
department of Ranchi Institute of Neuro-
Psychiatry & Allied Sciences (RINPAS),
Ranchi, Jharkhand. On the basis of purposive
sampling technique 30 caregivers of bipolar
affective disorder (currently mania) patients
(Group I) and 30 caregivers of schizophrenic
patients (Group II) were included in this study.
Caregivers of both the groups were
providing care for about mean total duration of
7 years and mean duration of contact was about
 Sampa Sinha / Perceived Social Support among the Family Members of Mentally Ill Patients
7 hours per day. Value of t-test shows that there
ZDVQRVLJQL¿FDQWGLIIHUHQFHEHWZHHQFDUHJLYHUV
of both groups regarding caregiving related
variables. Majority of caregivers (73.3% in both
groups) were regularly taking care of patients’
personal hygiene related matter and other
activities for daily living. Only 20% of caregivers
of group I and 16.7% caregivers of group II were
bringing patient to hospital for follow up etc. F2
engaged in supervision of medicine intake and
YDOXHVXJJHVWVQRVLJQL¿FDQWGLIIHUHQFHEHWZHHQ
the two groups in caregiving responsibility.
Socio-demographic and clinical
characteristics of patients suggest that mean age
of patients of group I was 34.47 ± 10.83 years and
mean education was 8.43 ± 2.90 years; mean age
of patients’ of group II was 34.17 ± 9.51 years and
mean education was 8.43 ± 4.05 years. Group
GLIIHUHQFH ZDV VWDWLVWLFDOO\ QRQVLJQL¿FDQW
Most of the patients of group I were male
(53.3%), married (66.7%), whereas, majority
of patients of group II were female (60%) and
equal proportion (43.3%) of the subjects were
found as either married or unmarried. In both the
groups majority of patients were unemployed
(63.3% in group I and 76.7% in group II). More
than one third patient in both the groups were
totally non-working. On comparison of socio-
demographic parameter in term of sex, marital
status, employment and working status ‘F2' value
suggests that these two groups did not show
VWDWLVWLFDOO\ VLJQL¿FDQW GLIIHUHQFH 0HDQ µDJH
of onset of illness’ of group I was 26.43 ± 9.57
years and mean of ‘total duration of illness’ was
8.10 ± 5.13 years. Whereas, in group II mean
‘age of illness onset’ was 24.03 ± 7.73 years and
mean of total ‘duration of illness’ was 10.27 ±
\HDUV9DOXHRIWWHVWVXJJHVWVQRVLJQL¿FDQW
difference. In both patient groups majority
of the patients were in relapse or full-blown
symptomatic condition.
caregivers of group I 14 (46.7%) were close
relatives (including siblings, offspring and other
family members), 9 (30%) were parents and
7 (23.3%) were spouses. Whereas, in group II
majority (60.0%) were close family members
(including siblings, offspring and others), 7
(23.3%) were parents and 5 (16.75%) were
spouses. Majority of family member/ caregivers
of both the groups were Hindu, male, married,
employed, residents of rural area, and belonging
from extended or joint families.
x
TOOLS
Scoio-demographic Proforma: A semi-
structured proforma was designed to collect
information about socio-demographic and
clinical characteristics, and other related
x
variables.
Social Support Questionnaire Short
Version (SSQ- short version) (Sarason et
al., 1983): Social Support Questionnaire
short version (SSQ- short version) has been
developed by Sarason et al. (1983) and it
has 6 items, which assess the size of the
subjects’ social network and their degree
of satisfaction with this network. This
scale is rated on 6-point scale. The mean
of these rating represents the subject’s
satisfaction with their support system. It
has two broad areas, namely, the number
of available people the individual can turn
at times of need of support in each of a
variety of situations, and the individual’s
degree of satisfaction with the perceived
available support. Separate factor analysis
of the two SSQ scales has shown the
number and satisfaction scores to be
composed of different, unitary dimensions
with only a moderate correlation (0.34)
between the two components. Test-retest
reliabilities were found 0.75 and 0.79 (4-
Respondents of the present study were
caregivers. Mean age of care-givers of group
I was 40.10 ± 9.81 years and of group II was
39.30 ± 9.04 years. Value of t-test suggests
QR VWDWLVWLFDOO\ VLJQL¿FDQW GLIIHUHQFH W 
p>0.05) between the two groups. Out of 30
25
ZHHNLQWHUYDODQGFRHI¿FLHQWDOSKDYDOXH
was found 0.90 and 0.93, respectively.
Since the local language ‘Hindi’ version
scale was not available so, all questions of
‘Social Support Questionnaire’ (SSQ) were
translated into Hindi, and then retranslated
 Sampa Sinha / Perceived Social Support among the Family Members of Mentally Ill Patients
into English by a different translator. After scale. Findings given in Table-1 shows majority
YHUL¿FDWLRQ QHFHVVDU\ PRGL¿FDWLRQ ZDV PDGH of the caregivers in both groups perceived
and the Hindi version of the interview schedule ‘poor’ social network (caregivers of mania =
ZDVWDNHQWRWKH¿HOGIRUSHUWHVWLQJ 80%; caregivers of schizophrenia 83%). Rest of
the caregivers in both groups (20% caregivers
PROCEDURE
of ‘mania; 16.6% caregivers of schizophrenia)
Data was collected at Out Patient
felt ‘average’ level of social network available
Department of Ranchi Institute of
Neuropsychiatry & Allied Sciences (RINPAS), to them.
Ranchi, Jharkhand India. Caregivers of mania Regarding ‘satisfaction’ with social
and schizophrenia patients were screened out network 40% of the caregivers of mania patients
according to inclusion and exclusion criteria. had ‘average’ satisfaction; one third (33.3%) of
After selection of subjects, socio-demographic them revealed ‘good’ satisfaction and nearly
data, Social Support Questionnaire short one fourth (26.6%) of them had ‘poor’ level
version (Local language Hindi version) were of satisfaction with social network. Whereas,
administered individually on caregivers. among caregivers of schizophrenia group
54% of the caregivers had ‘average’ level of
STATISTICAL ANALYSIS
satisfaction with social network, only 10% of
Data was described using number,
them had ‘good’ enough satisfaction and about
F2 and t-test were used.
percentage, mean and SD. For group comparison one third (36.6%) of the caregivers had ‘poor’
satisfaction with their available social network.
RESULT Mean and SD of the subjects, total score of
In the present study caregivers perceived perceived social support and satisfaction with
social support and its relation with the patient’s support is given in Table 2.
‘course of illness’ was studied. Details of
Table 2: Showing mean, SD, and ‘t’ value of
caregivers’ perceived social support variables
the Social Support between the caregivers of
are given in Table.1.
mania and caregivers of schizophrenia
Table 1:Showing social support between Care-givers Care-givers ‘t’
the caregivers’ of mania and caregivers’ of Variables Mania Schizophrenia value
‘schizophrenia’ Mean SD Mean SD df = 58
Social Support Social Satisfaction No. of Social
Network (n=%) 2.70 1.47 2.20 .1.03 .152
Support
(n=%)
Satisfaction
Good Group I - 10 (33.3%) 3.80 1.54 3.73 1.39 .176
with Support
Group II - 3 (10%) To know the difference of perceived
Average Group I 6 (20%) 12 (40%) social support among the caregivers’ or family
Group II 5 (16.6%) 16 (54%) members of the two study groups, ‘t’ test was
Poor Group I 24 (80%) 8 (26.6%) GRQH 6WDWLVWLFDOO\ QRQVLJQL¿FDQW GLIIHUHQFH
Group II 25 (83.4%) 11 (36.6%)
between the caregivers of both groups suggests
that caregivers of manic and schizophrenic
Group I = Caregivers of mania patients. patients face more or less similar problem in
Group II = Caregivers of schizophrenia patients. perceiving social support. It again suggests that
Perceived social support was studied the ‘course of illness’, i.e., episodic or continuous
in terms of ‘number of social network’ and course of psychiatric disorders, does not affect
‘satisfaction’ with available social network. or does not differ in perceiving social support of
Responses were categorized into three-point WKHFDUHJLYHUVDWDVWDWLVWLFDOO\VLJQL¿FDQWOHYHO

26
 Sampa Sinha / Perceived Social Support among the Family Members of Mentally Ill Patients
DISCUSSION
With increased demand on families
as caregivers, the perceived social support
or perceptions of support availability and
satisfaction needs to be included as an important
variable in studying the psychosocial need
of the caregivers of mentally ill individual.
However, studies in India are lacking in the
area of caregiver’s need and perception of
social support. The present study has applied
caregivers’ need based approach that aimed to
assess and understand their perceived social
support. Such information is important to chalk
out better family intervention programme in
order to improve the family member’s daily
living condition as well as to reduce caregiving
strain. This study was also intended to know and
compare the effect of different ‘course of illness’
of the patient on the perceived support of their
relatives, who were taking care of them.
Regarding caregivers related variables
the entire study sample (total 60) had an excess
of male, married caregivers who were close
relatives (including siblings, uncle, aunt and in
– laws) of the patient. Most of the caregivers
had rural based domicile background and were
from non nuclear families i.e., joint or extended
IDPLOLHV7KH SUHVHQW VWXG\ IROORZHG GH¿QLWLRQ
of primary caregiver given by das Changas
Mederios et al. (2000) as ‘responsibility for
care of the patient is taken by the member of the
family called the primary caregiver.
Analysis of ‘social support questionnaire’
domains suggests that relatives of mentally
ill patients reported poor social network but
perceived average to good level of satisfaction
with their available social network. Poor
availability of social network at time of need
may be explained in terms of their socio-cultural
conception of mental illness. For example, the
fear of being labelled as a family member of
mentally ill person and the consequences of
devaluation and discrimination may hamper
the family members from seeking help or even
perceiving ample number of social network
where they could reveal their family secrets
of mental illness and sought help in time of
27
distress. Link et al. (1999) in a study reported
that cultural conceptions of mental disorders
have harmful consequences for both the
family members and patients, for example, by
perceiving existent and non-existent barriers
as a major obstacle in help seeking behaviours.
Most of the subjects reported average
or above average level of satisfaction with
their available social network. Most of
the participants of our study were married,
belonging to rural based joint family or extended
family set up, where sense of togetherness and
shared responsibility is common in social and
family life. This may be one of the reasons for
having better perception of satisfaction with
social support even of having poor level of
social network. Recent studies reported that the
perceived social support and sense of satisfaction
with it is consistently linked to positive mental
health whereas, the received social support as
well as social integration are not (Uchino, 2009)
and the largest part of perceived social support
is relational in nature (Lakey, 2010; Lakey,
& Orehek, 2011). Silva and Silva (2001) also
suggested that joint family must be encouraged to
take and share caregiving related responsibilities
of a mentally ill patient as primary caregiver
would feel less-burden if they will get support
from other family members. The relational
regulation theory also supports the present
VWXG\ ¿QGLQJV ZKLFK H[SODLQ WKDW WKH RUGLQDU\
conversations and shared activities among close
connected people provide good support, reduce
stress and enhance positive mental health status
(Lakey, 2010; Lakey & Orehek, 2011).
In the present study regarding social
VXSSRUW WKHUH ZDV QR VWDWLVWLFDOO\ VLJQL¿FDQW
difference between both caregivers’ groups.
7KLV¿QGLQJVXJJHVWVWKDWWKHUHLVQRVLJQL¿FDQW
differential effect of the patients ‘course of
illness’ on the perception of social support
among the family members. In order to justify
DERYHPHQWLRQHG¿QGLQJVLWFDQEHVDLGWKDWDOO
caregivers of mentally ill patients carry very
similar psychological burden and are exposed to
similar situational stressors. Almost all primary
caregivers share similar fate in their life, which
 Sampa Sinha / Perceived Social Support among the Family Members of Mentally Ill Patients
is basically dominated by the fact that they
take responsibility for their mentally ill family
member. Some studies suggested caregivers of
patients of schizophrenia and bipolar affective
disorder face similar levels of burden (Nehra et
al., 2005) and often do not seek social support
as a coping method to deal with it (Chadda et
al., 2007). However, it can be said that among
the resources available to the caregiver, the
sense of mastery could be emerged as the most
important personal resource, which help to
enhance quality of relations in social life.
Findings of the present study suggest that
availability of social support network does not
necessarily determine the level of satisfaction.
Also the result of present study should be
interpreted in the light of its limitations. Study
was done on a small sample size. Coping
strategy is an important variable that was not
controlled. Further research in this area with
prospective design should be carried out for
better understanding of the caregivers’ socio
cultural life condition and it’s relation with
psychosocial factors like social support, family
support etc. All these information will give
an opportunity to professionals to design and
develop effective psychosocial intervention
programme in order to lessen their distress and
improve their quality of life.
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Indian Journal of Clinical Psychology Copyright, 2013 Indian Association of
2013, Vol. 40, No. 1, 29-33 Clinical Psychologists (ISSN 0303-2582)

Research Article
Underlying Psychological Factors among Cases under
Breast Cancer Treatment
O. S. Ravindran1 and N. Hemalatha2

ABSTRACT
Breast Cancer is the most common cancer among women and coping with the illness is a
challenge for any one. The aim of the present study is to compare the mental adjustment to
cancer, depression and quality of life of patients with breast cancer undergoing chemotherapy
or radiotherapy. Sixty patients diagnosed with breast cancer in the age-range of 30-60 years who
are attending as out-patients were divided into two groups on the basis of treatment modalities.
They were assessed by the following instruments: the Mental Adjustment to Cancer (MAC)
scale, Beck Depression Inventory (BDI-II) and Quality of Life – Cancer (QOL-C) scale. The
results indicated that patients in both groups adopted negative mental adjustment responses
and the chemotherapy group is more distressed than the radiotherapy group.
.H\ZRUGVBreast Cancer, Mental Adjustment, Depression, Quality of Life.
Breast cancer is the most common cancer well as decreased health related quality of life
among women. The lifetime risk of developing (Albert et al., 2004; Safaee et al., 2008).
the breast cancer in women is 12% (American There has been a growing interest in the
Cancer Society, 2009). The number of women area of coping with cancer. The theory of mental
diagnosed with breast cancer has increased adjustment to cancer is one of the most widely
as a result of mammography screening. The studied concepts with cancer patients (Grassi
incidence of breast cancer in India varied from
et al., 1993). Mental adjustment to cancer may
23 to 32 per 100,000 women (Annual Report,
EH GH¿QHG DV WKH FRJQLWLYH DQG EHKDYLRXUDO
National Cancer Registry Programme, 2005).
responses made by an individual to the diagnosis
The diagnosis of breast cancer is quite distressful
of cancer (Greer & Watson, 1987). Many studies
to women with breast cancer. The major areas
have suggested that cancer patients’ mental
of psychological distress for women diagnosed
adjustment is one of the important factors
with breast cancer relate to fear of death,
body image concerns, dealing physically and correlating with quality of life and degree of
emotionally with the side effects of treatment. psychological distress (Watson et al., 1991;
Ferrero et al., 1994). A follow-up study of
The treatment modalities for primary
early breast cancer patients revealed that those
breast cancer include surgery, chemotherapy,
ZKRUHVSRQGHGWRFDQFHUZLWK¿JKWLQJVSLULWRU
radiotherapy and hormonal therapy all four of
denial were more likely to be alive and free of
which can be used alone or in combination.
recurrence at a 15 year follow-up than those who
Adjuvant therapies such as chemotherapy
responded with stoic acceptance or helplessness/
and radiotherapy are commonly used after
primary treatment. Despite advances in cancer hopelessness (Greer et al., 1990).
treatment, the treatment related adverse effects Keeping in view of the above, the present
are major stressors in patients with breast cancer study was undertaken to compare the mental
undergoing treatment for the disease. As a adjustment to cancer, depression and quality of
consequence, they risk mood disorders such as life of patients with breast cancer undergoing
depression (Massie, 2004; McDaniel, 1995) as chemotherapy or radiotherapy.
1. Associate Professor of Clinical Psychology, Sri Ramachandra University, Porur, Chennai – 600 116 2. Clinical
Psychologist Corresponding author: Email: nirmalaravindran20@gmail.com

29
 O. S. Ravindran / Psychological Factors Underlying Breast Cancer
METHOD 2. Beck Depression Inventory (BDI-II) - (Beck
Sample et al., 1996).
The sample for the present study comprised The BDI-II was used to measure the
of 60 patients diagnosed with breast cancer in symptoms of depression. It consists of 21 item
sets, each with a series of four statements.
the age-range of 30-60 years. Potential subjects
Statements describe symptom severity along an
were recruited from the outpatient department
ordinal continuum from absent (a score of 0) to
of Cancer Institute, Chennai. Eligibility criteria severe (a score of 3). Depression severity scores
included: a) women diagnosed with stage I-III are created by summing the scores of the items
breast cancer and undergoing chemotherapy or endorsed from each item set. The most recent
radiotherapy. b) patients in the age-range of 30- guidelines suggest the following interpretation
60 years. c) patients who are willing to participate of severity scores: 0-13 minimal; 14-19 mild;
in the study. Those who have: a) other types of 20-28 moderate and 29-63 severe. The BDI-II
cancer. b) patients who are in critical condition, shows high internal consistency with a Cronbach
c) those who have any other major physical alpha of 0.92 in outpatients.
illnesses. d) had a history of psychiatric disorder 3. Quality of Life – Cancer (Vidhubala et al.,
were excluded from the study. After obtaining 2005)
permission from the hospital authorities, the The QOL-C is a 38 item questionnaire with
study was conducted in the cancer institute. ten factors namely, psychological wellbeing,
VHOIDGHTXDF\ SK\VLFDO ZHOOEHLQJ FRQ¿GHQFH
The patients were randomized and
in self ability, external support, pain mobility,
recruited in two groups: group I comprised of
optimism and belief, interpersonal relationship
30 patients who received chemotherapy, while DQG VHOIVXI¿FLHQF\ DQG LQGHSHQGHQFH *UHHU
group II consists of 30 patients who received and Watson, 1987). The QOL-C shows high
radiotherapy. Written informed consent was internal consistency with a Cronbach alpha of
obtained after the patient had been fully informed 0.90 in outpatients. The maximum score was
of the purpose of the study. The study sample 152 and the minimum score was 38. Higher
was assessed using the following instruments. score indicate better functional status.
Measures All subjects who consented were
interviewed. Their sociodemographic and
1. Mental Adjustment to Cancer (MAC) Scale
clinical details were collected, and they were
The MAC scale is a widely used self-
assessed by the MAC, BDI-II and QOL-C
rating questionnaire for cancer patients (Watson
VFDOHV )RU WKRVH ZKR H[SHULHQFHGGLI¿FXOW\ LQ
et al.,1998). It consists of 40 items and the
reading, the questions were read out and the
RULJLQDOIDFWRUVWUXFWXUHFODVVL¿HGWKHIROORZLQJ
responses were noted. The data was collected in
DGMXVWPHQW VW\OHV ¿JKWLQJ VSLULW KHOSOHVVQHVV
one session from each patient which lasted for
hopelessness, anxious preoccupation, fatalism
a duration of one hour. The respondents were
and avoidance. Avoidance scale was excluded
DVVXUHG RI WKH FRQ¿GHQWLDOLW\ 7KH µW¶ WHVW ZDV
from scoring as it consists of one item only.
FRPSXWHGWR¿QGRXWWKHGLIIHUHQFHEHWZHHQWKH
Items are given as statements and patients means.
assess their agreement using a four point Likert
scale. Scores for the subscales are calculated by RESULTS
adding up the answers of the assigned items. Information on demographic and clinical
7KH UHOLDELOLW\ FRHI¿FLHQW KDV EHHQ SURYHG WR characteristics of patients with breast cancer are
EHVDWLVIDFWRU\DOSKDFRHI¿FLHQWUDQJLQJIURP presented in Table 1.
0.61 to 0.81). Patients’ responses to having breast cancer

30
 O. S. Ravindran / Psychological Factors Underlying Breast Cancer
were measured using the mental adjustment to WKHUH LV QR VLJQL¿FDQW GLIIHUHQFH EHWZHHQ WKH
cancer scale and the results are shown in Table 2. two groups on the remaining factors. Patients
LQ ERWK JURXSV KDYH ¿JKWLQJ VSLULW DQ[LRXVO\
Table-1 : Socio-demographic and patient
preoccupied over cancer related worries and
characteristics more fatalistic. Patients in the chemotherapy
Variables Percentage (%) group are found to be devoid of hope and see
Age range (30-60 CT Group(30) 50.00 themselves as gravely ill than the radiotherapy
years) RT Group(30) 50.00
group on the factor of helplessness/hopelessness.
8-10th standard 43.33
Education 11-12th standard 21.67 Participants in the chemotherapy group shows
College 35.00 PRGHUDWH OHYHOV RI GHSUHVVLRQ DQG VLJQL¿FDQW
Occupation Employed 23.33 decline in the quality of life than the radiotherapy
Unemployed 76.67 group after the cancer treatment was initiated
Single - and the results are presented in Table 3.
Marital Status Married 68.33
Widowed 16.67 Table-3 : A comparison of depression and quality
Separated 15.00
of life grouped by types of cancer treatment
>Rs.7,000 33.33
Monthly Income
< Rs.7,000 66.67 Chemo-
Radiotherapy
CT RT therapy t- Level of
N=30
Factors N=30 val- OECJEł-
Stage I 50.00 53.40
ue cance
Stage of disease Stage II 46.70 33.30 M SD M SD
Stage III
3.30 13.30
Depression 21.10 9.96 9.98 7.14 4.98 0.01
Yes 58.33
Family history of
No 41.67 Quality of 124.47 16.84 142.53 16.40 3.28 0.01
cancer
life- cancer
CT-Chemotherapy RT-Radiotherapy
DISCUSSION
The age-range of the subjects was 30 to 60
Breast cancer is a life-threatening condition
years. A large number of subjects were married
and coping with the illness is a challenge for
(68.33%), had completed high school (43.33%),
any one. Mental adjustment and coping have
were not employed (76.67%) and have a family
EHHQ LGHQWL¿HG DV LPSRUWDQW IDFWRUV IRU KHDOWK
history of cancer. Half of the subjects in both
related quality of life and psychological state in
groups were diagnosed with stage 1 cancer FDQFHUSDWLHQWV7KH¿QGLQJVRIWKHSUHVHQWVWXG\
(50%). shows that patients in both groups responded to
Table-2 : A comparison of mental adjustment EUHDVWFDQFHUZLWK¿JKWLQJVSLULW7KLVFRXOGEH
to cancer grouped by types of cancer treatment possible due to the support of family members
as well as the strongest role played by their
Chemotherapy Radiotherapy
N=30 N=30 t- Level of SK\VLFLDQV 7KH DERYH ¿QGLQJ LV FRQVLVWHQW
Factors
Value 5KIPKſECPEG with those found in previous studies of cancer
M SD M SD
patients which revealed that social support
Fighting spirit 49.50 6.33 50.17 7.51 0.37 NS from family members (Hann et al., 1995) and
Helplessness/ 14.30 6.48 11.53 4.47 2.15 0.05 physicians (Slevin et al., 1996) are predictive of
hopelessness ¿JKWLQJVSLULWDQGH[WUHPHO\EHQH¿FLDOWRFDQFHU
Anxious pre- 23.73 4.25 21.50 5.13 1.83 NS patients and help them to cope better with their
occupation
illness.
Fatalism 22.10 3.45 21.13 3.28 1.11 NS
The negative mental adjustment responses of
16 1RWVLJQL¿FDQW helplessness / hopelessness, anxious preoccupation
The result presented in table 2 shows that and fatalism are associated with psychological
except the factor of helplessness / hopelessness, distress (Akechi et al., 2001). The theory of

31
 O. S. Ravindran / Psychological Factors Underlying Breast Cancer
mental adjustment emphasized that mental
adjustment includes emotional reactions to
a threatening event. The diagnosis of breast
cancer is a threatening event and patients
diagnosed with breast cancer cognitively
appraised their situation as stressful and
engaged in maladaptive adjustment responses
such as helplessness/ hopelessness, anxious
preoccupation and fatalism. They are devoid
of hope and see themselves as gravely ill and
showed a negative impact in their mental health.
7KHDERYH¿QGLQJLVVLPLODUWRDSUHYLRXVVWXG\
of breast cancer patients who were involved in
greater use of disengagement coping strategies
(Epping-Jordan et al., 1999).
In this study, it was found that depression
was higher in those subjects undergoing
chemotherapy than in those receiving
UDGLRWKHUDS\7KH¿QGLQJVUHÀHFWWKRVHUHSRUWHG
in other studies (Burgess et al., 2005; Hopwood et
al., 2007). Since this study excluded the patients
with a history of psychiatric disorder, depressive
symptoms are likely to be caused by severe
treatment side-effects from chemotherapy (Rao
et al., 2009) and other possible reason include
low self-esteem due to changes in their physical
appearance caused by the side-effects of the
treatment. Another reason may be uncertainty
about the recurrence of cancer in patients
undergoing chemotherapy may also cause higher
OHYHOVRIGHSUHVVLRQ6LPLODU¿QGLQJVKDYHEHHQ
reported by other researchers (Van Den Beuken
et al., 2008). The present study also found
that participants in the chemotherapy group
H[SHULHQFHG VLJQL¿FDQW GHFOLQH LQ WKHLU TXDOLW\
of life than those in the radiotherapy group. The
¿QGLQJV SURYLGH HYLGHQFH WKDW SV\FKRORJLFDO
distress have a detrimental effect on the physio-
psycho-social wellbeing of patients during the
FDQFHU WUHDWPHQW 6LPLODU ¿QGLQJV DUH UHSRUWHG
in other studies (Ganz et al., 2003; Kenne et
al., 2007). Psychological interventions such as
crisis cancer counselling can be useful to restore
a sense of control, instill hope, clarifying the
ambiguities and mobilizing the coping resources
soon after the diagnosis of breast cancer was
32
made. Cognitive behavior therapy techniques
such as education about cancer, cognitive
reappraisal and promotion of enhanced coping
can be useful to reduce depressive symptoms
and to enhance physical functioning (Scheier et
al., 2005).
Although the study gives interesting
¿QGLQJVLWKDVVHULRXVOLPLWDWLRQV7KHSUHVHQW
VWXG\ LV FRQ¿QHG WR D VPDOO VDPSOH RI EUHDVW
cancer patients undergoing cancer treatment on
out-patient basis and focused only on studying
their mental adjustment to cancer, depression and
quality of life. In future research, longitudinal
studies can be done to study the psychological
symptoms experienced by other types of cancer
patients at the start of treatment and post-
treatment. The psychological symptoms may
UHGXFHWKHHI¿FDF\RIFKHPRWKHUDS\LQFDVHVRI
breast cancer. The psychological distress may
cause stress which alters hormonal and neuronal
secretions and affects the biological activity of
breast cancer cells. Therefore, early detection
of psychological symptoms and provision of
effective psychological treatment to reduce the
distress may well maintain the effectiveness of
cancer treatment.
To conclude, patients in the chemotherapy
group are experiencing moderate depressive
V\PSWRPV ZLWK VLJQL¿FDQW UHGXFWLRQV LQ WKHLU
quality of life and the maladaptive coping
strategies are employed by both groups of breast
cancer patients.
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Indian Journal of Clinical Psychology Copyright, 2013 Indian Association of
2013, Vol. 40, No. 1, 34-40 Clinical Psychologists (ISSN 0303-2582)
Research Article
Loss, Trauma and Suicidal Ideation among Women Living in a Shelter
L. N. Suman1 and B. V. Sesha2

ABSTRACT
Stress is very common phenomenon among women living in shelter. the present study is
concern with the loss, trauma and suicidal ideation among women living in shelter. Between
2002 and 2010, life histories, interviews and information obtained from standardized rating
VFDOHVKDGLQGLFDWHGVLJQL¿FDQWGLVWUHVVDPRQJZRPHQOLYLQJLQDUHKDELOLWDWLRQKRPHLQ
South Bangalore. The aim of the present investigation was to examine factors related to the
distress and to assess the suicidal ideation. The sample consisted of 93 women in the age
range of 16 to 47 years (Mean age: 20.38 years). 33 women had been raised in orphanages
from a young age and the rest had been placed in the shelter by family members. A semi-
structured interview and Beck’s Scale for Suicide Ideation were used to collect information.
Results revealed that 65% of women who had experienced disintegration of their families
DQGRIZRPHQUDLVHGLQLQVWLWXWLRQVZHUHVLJQL¿FDQWO\GLVWUHVVHG,QWHUYLHZVUHYHDOHG
multiple themes related to loss, abuse and trauma in childhood and adolescence. Loss of
parents, loss of home, physical and psychological abuse, neglect and deprivation were
reported as particularly traumatic. Subjects who reported such experiences scored higher
RQWKHVFDOHIRUVXLFLGHLGHDWLRQ7KH¿QGLQJVLQGLFDWHWKDWZRPHQOLYLQJLQVKHOWHUVPD\EH
vulnerable for developing serious emotional problems especially if they have experienced
DGYHUVH FKLOGKRRG H[SHULHQFHV 7KH ¿QGLQJV LPSO\ WKDW LW LV QHFHVVDU\ WR VFUHHQ ZRPHQ
living in shelters for trauma and suicidal ideation in order to plan effective interventions.
Key Words: Women, Shelter, Loss, Trauma, Suicidal Ideation

INTRODUCTION period. They are likely to be younger and least

Homeless individuals and families are
a very diverse and generally a multiproblem
population. Although homeless individuals have
VLJQL¿FDQWHPRWLRQDOQHHGV/LWHUDWXUHLQGLFDWHV
that the homeless are seriously underserved
therapeutically (Hertlein & Killmer, 2004).
Further, women seeking care and protection in
shelter homes come from various challenging
situations. Understanding the psychological
needs of the women in shelter homes is crucial
to address and plan comprehensive psychosocial
care. The reason for institutionalization can be
viewed as a result of contextual factors that
interact with individual and family vulnerabilities
as had been reported by Suman (2005a).
likely among the homeless to have mental health,
substance abuse or other medical problems. They
become homeless due to some catastrophic event
such as the death of the house holder and may
have already exhausted the option of doubling
up with friends or relatives. The second cluster
was labelled the episodically homeless, who
frequently shuttle in and out of homelessness.
Such people are also more likely to be young,
but often experience medical, mental health
and substance abuse problems and are often
chronically unemployed. The third subgroup was
named the chronically homeless. These are people
for whom shelters are more like long-term housing
than an emergency arrangement. They are older
.XKQ DQG &XOKDQH  LGHQWL¿HG WKUHH than other homeless group people and consist of
groups of homeless people through cluster the hard-core unemployed, often suffering from
analysis: the transitionally homeless, who disabilities and substance abuse problems. The
generally enter the shelter system for a short problems and needs of these groups differ and it

1.Professor,DepartmentofClinicalPsychology,NationalInstituteofMentalHealthandNeurosciences(NIMHANS),Bangalore:
560 029. 2. Lay Counselor and Honorary Secretary, Abalashrama, D.V.G. Road, Basavanagudi, Bangalore: 560 004,
Corresponding Author - E mail: elenes@nimhans.kar.nic.in

34
 L. N. Suman / Loss, Trauma and Suicidal Ideation among Women Living in a Shelter
is important to plan interventions that are suitable
for a given group member.
+RPHOHVVQHVVLVDGLI¿FXOWDQGFKDOOHQJLQJ
situation which is linked to traumatic experiences
OHDGLQJ WR VLJQL¿FDQW HPRWLRQDO DQG DGMXVWPHQW
problems. Yoder et al. (2008) examined
associations among dimensions of suicidality and
psychopathology in a sample of 428 homeless
adolescents (56.3% were female) with a mean
DJHRI\HDUV&RQ¿UPDWRU\IDFWRUDQDO\VLV
results provided support for a three-factor model
in which suicidality, internalizing disorders
and externalizing disorders were positively
intercorrelated. They recommended that future
studies should use prospective data or current
measures of suicidality and psychopathology.
They concluded that youths should be screened
across the spectrum of suicidality (from thoughts
of death and suicide to plans and attempted
suicide) and both internalizing and externalizing
problems. Bender et al. (2010) examined
correlates of trauma and post-traumatic stress
disorder in a sample of 146 homeless youth in
the age range of 18 to 24 years. Results indicated
that 57% had experienced a traumatic event and
24% met criteria for PTSD. Those reporting more
WUDXPD KDG ORZHU VHOIHI¿FDF\ KLJKHU DOFRKRO
abuse and mood disorder. They recommended
that future studies should examine the underlying
structure of psychological diagnoses in this
population and examine potential comorbid
disorders related to trauma.
Hopper et al. (2010) also noted that
an overwhelming percentage of homeless
individuals, families, and children would have
been exposed to various forms of trauma such
as neglect, psychological abuse, physical
abuse, and sexual abuse during childhood.
7KH\ GH¿QHG WUDXPD DV µDQ H[SHULHQFH WKDW
creates a sense of fear, helplessness, or horror,
and overwhelms a person’s resources for
coping’. The impact of traumatic stress can
be devastating and long-lasting in vulnerable
individuals who may develop depression or
post-traumatic stress disorder. They recommend
directly address the impact of trauma, with the
goals of decreasing symptoms and facilitating
recovery. More recently, in a phenomenological
study, McBride (2012) explored the experiences
and needs of 11 individuals of the homeless
population and found that they felt isolated, used
negative coping strategies such as substance use
and had fears about their safety.
In a recent study in India by Sekar (2011)
on 30 residents of a government shelter home,
results revealed that 40% of the women had been
DUUHVWHGXQGHUWKH,PPRUDO7UDI¿FNLQJ3UHYHQWLRQ
Act (ITPA) and were placed in the shelter for
rehabilitation. 30% of the residents went against
the wishes of their family and eloped with their
boyfriend who deceived them eventually. They
then sought refuge in the shelter as their families
were not willing to take them back. The analysis
further revealed that 13.3 % were admitted to
the shelter to protect them from dowry, abuse,
desertion and domestic violence. The rest had
been admitted due to abandonment by the
family, stigma related to unwed pregnancies and
interpersonal problems, especially ill-treatment
E\ VWHSPRWKHU 7KHVH ¿QGLQJV DUH VLPLODU WR
those reported recently by Mayock and Sheridan
(2012), who in their study of 60 women in the age
range of 18 to 62 years, found that homelessness
was a culmination of a complex range of
experiences such as multiple adversities, poverty
DQGGLI¿FXOWIDPLO\VLWXDWLRQV
However, there are few systematic,
published Indian studies on subjective
experiences of homeless women about their life
circumstances. Very little is known about their
fears and hopes. Although the study by Suman
(2005b) on a sample of 55 women had noted that
PRUHWKDQRQHWKLUGRIWKHPZHUHVLJQL¿FDQWO\
distressed and about 18% had high suicidal
LGHDWLRQ,QDODWHUVWXG\RQ¿UVWWLPHKRPHOHVV
women, Suman (2008) reported that issues
related to multiple losses led to trauma and
hopelessness. Such studies are required in the
Indian setting to understand the perceived needs
of the women for psychosocial interventions and
WKH XVH RI 7UDXPD6SHFL¿F 6HUYLFHV 766 to plan suitable programs for both alleviating
which include interventions that are designed to distress and for rehabilitation.

35
 L. N. Suman / Loss, Trauma and Suicidal Ideation among Women Living in a Shelter
The aims of the present study were: (i) To
examine the antecedent factors of homelessness
in a sample of women staying in a shelter for
homeless women
(ii) To explore subjective experiences related
to homelessness
(iii) To assess suicidal ideation at the time of
the study
METHOD
Sample:
The sample consisted of 93 girls and
women in the age range of 15 to 47 years living
in a shelter. All of them hailed from Karnataka, a
State in South India. 55 (59.14%) were from urban
areas and 38 (40.86%) were from rural areas.
Measures:
(i) Sociodemographic Data Sheet: This
was used to obtain information about
the residents’ age, education, duration
of homelessness, age when rendered
homeless and duration of stay in the
present shelter.
(ii) Semi-structured Interview Schedule
for Homeless Women (Suman, 2005):
This schedule was used to get information
about reasons for homelessness, details
about parents and siblings (if known),
details about other relatives (if known),
upbringing during childhood and
adolescence, and overall functioning of
the individual at the time of the study
(Physical Health, Emotional Experiences,
Interpersonal and Social Relationships,
Self-image, Academic Performance and
Attitude towards Future).
(iii) Beck’s Scale for Suicide Ideation (BSSI)
(Beck et al., 1979): This is a 19 item scale
designed to quantify and assess suicidal
intention. Each item consists of three
alternative statements graded in intensity
from 0 to 2. The total score is computed by
adding the individual item scores. Thus,
the possible range of scores is 0-38. The
SSI is completed based on the subject’s
answers in a semi structured interview. It
36
KDV D KLJK FRHI¿FLHQW DOSKD RI  DQG
DQ LQWHU UDWHU UHOLDELOLW\ FRHI¿FLHQW RI
0.83. Its discriminative validity has been
established clinically and factor analysis
of the scale indicated 3 components:
Factor 1: Active suicidal desire; Factor
2: Preparation; Factor 3: Passive suicidal
desire.
Setting of the Present Study :
Abalashrama is a rehabilitation home
situated in South Bangalore which was
established in 1905. It is meant to provide shelter
exclusively to girls (above 16 years) and women
rendered homeless and indigent. It can house 40
people at any given point of time. It provides
dormitory type accommodation to the residents.
It houses a large assembly room; kitchen;
GLQLQJ URRP VWRUH URRP SUD\HU URRP RI¿FH
rooms and washrooms. A large new building is
being constructed to house vocational training
facilities.
Procedure :
Permission for the study was obtained
from the management of the shelter. Informed
consent for the study was obtained individually
from all the subjects. Privacy and a comfortable
atmosphere during the interview were ensured.
Interviews and assessment on the rating scale
were carried out in individual sessions. Duration
of the sessions were about 60 minutes on an
average. Data were analyzed using descriptive
statistics such as percentages, means and
standard deviations. Findings were conveyed to
the management of the shelter.
RESULTS
Table 1: Sociodemographic details of the
sample (N=93)
Mean SD
Age (in years) 20.38 4.37
Education (in years) 9.59 2.81
Duration of homelessness (in years) 5.38 5.29
Age when rendered homeless (in years) 10.47 7.64
Duration of stay in the present shelter 2.32 1.59
(in years)
 L. N. Suman / Loss, Trauma and Suicidal Ideation among Women Living in a Shelter
Table 1 indicates that the sample
comprised predominantly of young women
who had completed on an average 10 years of
schooling. More than 50% of them had lost their
fathers and more than 60% had lost their mothers
when they were quite young and had been in
shelters for more than a decade at the time of
the study. Major reasons for homelessness were,
GHDWKRISDUHQWVLQWHUSHUVRQDOFRQÀLFWVZLWKWKH
VLJQL¿FDQWGLVWUHVVUHODWHGWRWKHLUFKLOGKRRGDQG
adolescence periods.
Information from interviews revealed
that more than a quarter of the residents had
experienced adverse childhood circumstances as
a result of alcohol dependence in their fathers
DQG FRQVHTXHQW ¿QDQFLDO SUREOHPV SK\VLFDO
abuse, neglect and domestic violence. About
 KDG H[SHULHQFHG GLI¿FXOWLHV DV D UHVXOW RI
VWHSSDUHQW VWHSPRWKHU LQ DOO FDVHV ¿QDQFLDO
GLI¿FXOWLHV RI UHODWLYHV ZKLFK SUHYHQWHG WKHP
from looking after an additional family member
even when they wanted to, ill treatment by
guardians, and reluctance to look after a girl
child by some relatives as it entailed more
responsibility and expenditure. These sample
characteristics indicate that the women belonged
to the transitionally homeless subgroup as
mental illness, alcohol dependence and suicide
in their mothers. Two residents had witnessed
incestuous relations between their fathers and
elder sisters and were frequently traumatized by
recurrent images and memories of the events.
Five residents were ostracized from their
families due to stigma following rape and two
were ostracized from their families due to being
a burden as a result of physical disability. Six
FODVVL¿HGE\.XKQDQG&XOKDQH residents had separated from their husbands
due to marital discord involving violence.
Table 2: Nature of Memories related to
They did not receive support from their parents
Childhood and Adolescence and siblings and were forced to seek safety in
Raised by Raised in Total - 93 shelters.
Family Orphanages (100%)
60 (64.52%) 33 (35.48%) Table 3: Nature of trauma reported by the
subjects
Pleasant 21 (35%) 25 (75.76%) 46
Memories (49.46%) Severe physical, emotional and social abuse
Unpleasant 39 (65%) 8 (24.24%) 47 Neglect and rejection for being a girl child
Memories (50.54%)
As seen in Table 2, an almost equal number Poverty and forced labour to sustain daily living
of residents reported pleasant and unpleasant Harsh physical punishment and verbal abuse
memories of their childhood and adolescence
Lack of encouragement to study
periods (about 50% each). However, the patterns
RIVXFKPHPRULHVZHUHIRXQGWREHVLJQL¿FDQWO\ Restrictions on socializing and making friends
different when the residents were grouped
KJŃE?POSEPDOPALIKPDANO
CQ=N@E=JO
NAH=PERAO
according to whether they had been raised
by their parents and other family members or Separation from children and fears about loss of custody
whether they had been raised in institutions. Fears about the future, including retaining sanity
Three fourths of those raised in institutions
reported several pleasant memories related to Fears about early mortality in view of early deaths of
parents
their upbringing and often missed their friends
and caregivers with whom they had developed Results summarized in Table 3 give details
VLJQL¿FDQWDWWDFKPHQW2QWKHRWKHUKDQGRQO\ of the nature of trauma experienced by the
about one third of those raised by their families residents. The trauma was experienced at the
reported pleasant memories of growing up. Two hands of parents, relatives and other caregivers
thirds of those raised by family members and a by more than two thirds of those raised in their
quarter of those raised in institutions reported own homes. Eight residents (24.24%) raised in

37
 L. N. Suman / Loss, Trauma and Suicidal Ideation among Women Living in a Shelter
shelters reported traumatic experiences such as did not have active suicidal ideas. They had
verbal and physical abuse as well as overwork reported pleasant memories of their childhood
in the shelters where they were raised. and adolescence and were able to cope well with
the shelter conditions.
7DEOH7KHPHVRIORVVLGHQWL¿HGLQWKH
interviews Seven residents who scored between 8
and 9 on BSSI had moderate depressive features
Intrapersonal Interpersonal and Social
Losses Losses
and ideas of suicide but no active plans. They
had experienced verbal abuse and neglect
)KOOKBOAHB?KJł@AJ?A Loss of Parents in their childhood and adolescence but not
self-esteem
physical abuse. 9 residents who scored between
Loss of perceived dignity Loss of ties with siblings 10 and 15 on BSSI had severe depressive
Loss of trust in relatives and Loss of family identity
features and active suicidal plans. They had
people in general also contemplated the best ways of committing
suicide and the best time to complete the act.
Loss of motivation to plan for Loss of old neighbors and
the future friends
The best ways of committing suicide were
found to be either hanging or drowning and
Loss of will to live, especially Loss of house and its the best time for such acts were found to be
with strangers associated safety/security
between 2am and 4am. The 9 residents who
Interviews revealed frequent expressions KDGVLJQL¿FDQWGHSUHVVLYHIHDWXUHVDQGVXLFLGDO
of multiple losses. These have been categorized ideation had experienced more severe trauma
under ‘Intrapersonal Losses’ and ‘Interpersonal such as domestic violence, were victims of rape
and Social Losses’. The details are shown in and had witnessed incestuous relations between
Table 4. Most of the subjects were overwhelmed their fathers and older sisters. They continued to
with emotions while narrating their experiences suffer from recurrent memories about the abuse,
and frequently broke down in tears. especially the suffering of their mothers. They
Table 5: Suicidal ideation scores of the DOVRUHSRUWHGVLJQL¿FDQWDQJHUDERXWWKHLUSDVW
subjects had low self-concept and were not motivated to
plan for their future.
BSSI Scores Number of Percentage of
(Range) Residents DISCUSSION
Residents

0-3 56 60.21%
7KH ¿QGLQJ WKDW WKUHH IRXUWKV RI WKRVH
who were raised in institutions had pleasant
4-7 21 22.58% memories may be due to the fact that they did
8-9 7 7.53% not experience traumatic events such as loss
of parents, home and valued relationships at a
10-15 9 9.68% vulnerable age. This may be a protective factor
As it is evident from Table 5, two thirds apart from good quality shelter care reported by
of the residents had recovered quite well from Suman (2005a). Family disintegration and the
past trauma at the time of the study and scored subsequent loss of feelings of security appear
below 4 on BSSI. They attributed their recovery to be critical in the experience of trauma. In a
to good care at the shelter they were currently VXEVDPSOH RI ¿UVW WLPH KRPHOHVV ZRPHQ LQ
OLYLQJ LQ DQG GHULYLQJ VWUHQJWK DQG FRQ¿GHQFH the same shelter (n=25), Suman (2009) had
from others. Almost a quarter of the women found that loss of loved ones, loss of familiar
were on the road to good recovery and scored surroundings and loss of personal space caused
between 4 and 7 on BSSI. They had mild VLJQL¿FDQW GLVWUHVV WR WKH KRPHOHVV $OO WKH
depressive features and occasional feelings of subjects perceived homelessness as a traumatic
hopelessness and death wishes. They however experience and desired less rigid institutional

38
 L. N. Suman / Loss, Trauma and Suicidal Ideation among Women Living in a Shelter
UXOHV7KHVH¿QGLQJVKDYHEHHQFRQ¿UPHGLQWKH
present study on a larger sample which included
ERWK ¿UVW WLPH KRPHOHVV JLUOV DQG ZRPHQ DV
well as those raised primarily in institutions and
those who had experienced shelter life earlier
elsewhere.
Two thirds of women who had been placed
in the shelter by relatives appear to have been
raised in dysfunctional families. Their reports of
abuse and trauma at the hands of their parents
and other family members indicate the problems
faced by girls in households with mentally ill
parents and parents with substance use disorders.
7KH¿QGLQJVRIWKHSUHVHQWVWXG\DOVRUHYHDOHG
that girls are treated as a burden if they are
physically disabled and may become homeless
LIWKHLUFDUHJLYHUVGRQRWKDYHDGHTXDWH¿QDQFLDO
resources to look after them for a lifetime.
Further, banishment from the home after being
raped indicates the patriarchal attitude of the
families involved and the misplaced sense of
family honour. Goodman, Saxe and Harvey
that violence also often affects women’s sense
of belonging, control and self-worth, affecting
WKHLU VHOIFRQ¿GHQFH DQG VHOIHVWHHP DV ZHOO DV
social connectedness. Social isolation happens
when such women are without a cultural network
or when they lack other community networks
or when they have no relationships except their
husbands and their in-laws.
Results from the present study indicate that
those who had experienced no trauma or less
trauma (82.80%) were emotionally more stable
and had adjusted well to the requirements of life
LQ D VKHOWHU  6LJQL¿FDQW WUDXPD VXFK DV EHLQJ
victims of sexual abuse, domestic violence and
witnessing incest led to more severe depression
and slower recovery in 16 (17.20%) women.
7KLV ¿QGLQJ LQGLFDWHV WKH QHHG WR VFUHHQ
ZRPHQ LQ VKHOWHUV IRU VLJQL¿FDQW HPRWLRQDO
distress in order to provide mental health
interventions. Bender, et al. (2010) recommend
that youths should be systematically screened
for PTSD symptoms and clinicians should aim
 KDG QRWHG WKDW D VLJQL¿FDQW SURSRUWLRQ
of homeless people, especially women, have
histories of traumatic victimization. These
include physical abuse, sexual abuse and social
GLVDI¿OLDWLRQ 0DQ\ KRPHOHVV ZRPHQ PD\
therefore bring symptoms of psychological
trauma to their new circumstances. Martijn and
Sharpe (2006) had also reported that trauma was
a common experience prior to homelessness and
¿JXUHGLQWKHFDXVDOSDWKZD\VWRKRPHOHVVQHVV
Homelessness due to marital discord and
domestic violence found in six women in the
current study highlights the vulnerability and
helplessness of women in their own homes. The
women were either forced to leave their houses
or left on their own accord to escape domestic
misery. The lack of support from their parents and
siblings indicates the reluctance of Indian society
to continue caring for daughters who have been
‘given away in marriage’ and who ‘bring disrepute
to the family by leaving the marital home’. Tually
and Slatter (2008) noted that women escaping
from domestic violence are likely to become
homeless if they do not have the resources to
set up alternate accommodation. They opined
39
to understand the cumulative effects of the
youths’ traumatic experiences by determining
the number of traumatic events experienced,
the severity of symptoms and impairment, and
the meaning of the traumatic exposure to the
individual. These should be followed by trauma
focused psychotherapies in homeless youth
serving agencies.
For instance, Vicente et al. (2004) examined
the effects of an emotional disclosure protocol on
a group of eight homeless people using a single
group design. Each participant underwent four
individual one hour sessions over two weeks.
Each session included a twenty minute written
expression exercise, followed by a twenty minute
verbal expression exercise. Follow-up after six
weeks indicated improvements in depression,
perceived stress, and working memory tasks.
Further, it must be noted that although Suman
and Sesha (2010) reported promising results
from efforts at psychosocial rehabilitation in
the same shelter, all the residents had received
individual counseling and/or psychotherapy
before vocational and social rehabilitation plans
were implemented.
 L. N. Suman / Loss, Trauma and Suicidal Ideation among Women Living in a Shelter
Mc Bride (2012) recommended that
counsellors should plan to help clients deal
with the psychological implications of being
homeless, such as depression, suicidal ideation,
and anxiety. Further he noted that “it may be
helpful if counsellors advocated for the homeless
SRSXODWLRQ WR LQÀXHQFH V\VWHPLF FKDQJHV LQ
policy and service delivery for the mental health,
safety, and rehabilitation of homeless people, as
well as to prevent homelessness itself.”
Implications and Conclusions
Although social and economic factors
are important to understand pathways to
homelessness, it is equally important to address
the mental health needs of this marginalized
population. Women in shelters rarely get
access to psychological counseling which can
aid them in overcoming trauma and provide
them hope about the future. This can hamper
adequate emotional recovery and prevent
successful rehabilitation especially in terms of
building new, mature, long-lasting and trusting
relationships with people and learning to fend for
WKHPVHOYHV ZLWK LPSURYHG VHOIFRQ¿GHQFH DQG
emotional stability. It is important for agencies
Hopper, E. K., Bassuk, E. L., & Olivet, J. (2010). Shelter from
the storm: Trauma-informed care in homelessness
services settings. The Open Health Services and
Policy Journal, 3, 80-100.
Kuhn, R., & Culhane, D. P. (1988). Applying cluster
analysis to test a typology of homelessness by pattern
of shelter utilization: Results from the analysis of
administrative data. American Journal of Community
Psychology, 26, 207-232.
Martijn, C., & Sharpe, L. (2006). Pathways to youth
homelessness. Social Science and Medicine, 62, 1-12.
Mayock, P., & Sheridan, S. (2012). Women’s ‘Journeys’ to
Homelessness: Key Findings from a Biographical
Study of Homeless Women in Ireland. Research Paper
1: Dublin: School of Social Work and Social Policy
and Children’s Research Centre, Trinity College
Dublin.
McBride, R. G. (2012). Survival on the streets: Experiences
of the homeless population and constructive
suggestions for assistance. Journal of Multicultural
Counseling and Development, 40, 49-61.
Sekar, K. (2011). Psychosocial Care for Women in
Shelterhomes 8QLWHG 1DWLRQV 2I¿FH RQ 'UXJV DQG
&ULPH5HJLRQDO2I¿FHIRU6RXWK$VLD1HZ'HOKL
Suman, L. N. (2005a). Psychosocial issues in relation
to homeless women: A preliminary study. Indian
Journal of Clinical Psychology, 32, 85-90.
Suman, L. N. (2005b). Distress among homeless women.
Indian Journal of Social Psychiatry, 21, 41-47.
involved in running shelter homes to recognize
the psychological needs of the girls and women
and provide them with psychological services on
a regular basis in order to improve their quality
of life and to turn them into well functioning
individuals who can be assets to society.
References
Beck, A.T., Kovacs, M., & Weissman, A. (1979). Assessment
of suicidal intention: The scale for suicide ideation.
Journal of Consulting and Clinical Psychology, 47,
343-352.
Bender, K., Ferguson, K., Thompson, S., Komlo, C., &
Pollio, D. (2010). Factors associated with trauma and
post-traumatic stress disorder among homeless youth
in three U.S. cities: The importance of transience.
Journal of Traumatic Stress, 23, 161-168.
Goodman, L., Saxe, L., & Harvey, M. (1991). Homelessness
as psychological trauma: Broadening perspectives.
American Psychologist, 46, 1219-1225.
Hertlein, K. M., & Killmer, J. M. (2004). Toward
differentiated decision-making: Family systems
theory with the homeless clinical population. The
American Journal of Family Therapy, 32, 255-270.
40
6XPDQ / 1  $Q DQDO\VLV RI QDUUDWLYHV RI ¿UVW
time homeless women. Indian Journal of Social
Psychiatry, 24, 93-99.
Suman, L. N., & Sesha, B. V. (2010). Psychosocial
rehabilitation of young homeless women. Journal of
Psychosocial Research, 5, 47-53.
Tually, S., & Slatter, M. (2008). Women, Domestic and
Family Violence and Homelessness: A synthesis
Report. Flinders Institute for Housing, Urban and
Regional Research. Flinders University, Adelaide.
Vicente, A. D., Munoz, M., Santos, E., & Santos-Olmo, A.
B. (2004). Emotional disclosure in homeless people: A
pilot study. Journal of Traumatic Stress, 17, 439-443.
Yoder, K. A., Longley, S. L., Whitbeck, L. B., & Hoyt, D.
R. (2008). A dimensional model of psychopathology
among homeless adolescents: Suicidality, internalizing
and externalizing disorders. Journal of Abnormal
Child Psychology, 36, 95-104.
Indian Journal of Clinical Psychology Copyright, 2013 Indian Association of
2013, Vol. 40, No. 1, 41-48 Clinical Psychologists (ISSN 0303-2582)
Research Article
A Qualitative Study of Parents’ Reasoning and Decision Making
Process in Career Choice for their Children
Anisha Juneja1 and Naveen Grover2

Abstract:
The present study aimed to understand the parents’ reasoning and decision making process
in career choice for their children and its impact on parents’ mental health. The research
was designed primarily in the qualitative mode as it caters to a subjective experiential realm
of the parents. The participants were 20 parents of children enrolled in classes 9th to 12th in
Delhi schools selected through snowball sampling method. General Health Questionnaire-12
was used to rule out psychiatric morbidity and a semi structured interview schedule was
VSHFL¿FDOO\GHVLJQHGIRUWKHVWXG\)DFHWRIDFHLQWHUYLHZVRIPLQXWHVZHUHWUDQVFULEHG
and analysed using thematic analysis. Result suggest Parents’ reasoning was found to be
based on child, parent and future related factors in arriving at a suitable choice, being
inductive, deductive or conditional in nature. Parents’ decision making was either based
on rational models or deviated from rational models wherein either the index person or
participants’ expectations and desires determined career choice. Mental heath impact of the
SURFHVVZDVGH¿QHGE\SDUHQWVLQWHUPVRIUROHUHVSRQVLELOLW\IXO¿OOPHQWSKDVHFRQIXVLRQ
distress creating phase that brought about changes in social and occupational routines, a
protective function serving phase with a positive appraisal of the resulting changes. The
study has mental health implications in terms of making the process more collaborative and
planned between the parent-child dyad that ensures a better quality of life for both.
Keywords: Mental Health, Thematic Analysis, QOL, Psychological Process, Occupation

Introduction: their children. This affects their mental health

Career is the sequence of major positions
occupied by a person throughout his/her
pre-occupational, occupational and post-
occupational life including work related roles
such as those of student, employee, pensioner,
together with complementary vocational,
familial and civil roles (Super, 1990). Thus,
career decision making becomes a task that
UHTXLUHVSODQQLQJDVLWLVDPHDQVRIIXO¿OPHQW
of physical, social, psychological and emotional
needs of both the child and the parents. High
VFKRRO LV D WLPH ZKHQ VLJQL¿FDQW GHFLVLRQV
about the adolescent’s future educational and
FDUHHUSDWKVDVZHOODVLGHQWL¿FDWLRQRIKLVKHU
aspirations, setting of their educational and career
goals begin (Lapan, 2004). Pressure for high
DFDGHPLF DFKLHYHPHQW ZLWK ¿HUFH FRPSHWLWLRQ
for admission into higher education starts
building up on the parents as well apart from
which is a state of complete physical, mental and
social well-being, and not merely the absence of
disease wherein the individual realizes his or her
own abilities, can cope with the normal stresses
of life, can work productively and fruitfully and
is able to make a contribution to his or her own
community (WHO, 2001). With respect to the
pre-occupational position in career, Shoffner and
Klemer (1973) and Hairston (2000) suggested
that parents affect their children’s career choices
intentionally or unintentionally by acting as role
PRGHOV LQÀXHQFHV RQ FKLOGUHQ¶V VHOIFRQFHSW
occupational motivators, job information
resources, and providers of the developmental
environment with exposure of children to
implied expectations. There have been various
theories proposed to understand factors affecting
reasoning and career decision making such as
threshold approach to choice model (Clemen,

1. Clinical Psychologist, Delhi. 2. Assistant Professor, Department of Clinical Psychology, IHBAS, Dilshad Garden, Delhi-95.
Corresponding Author Email - grover.nav@gmail.com

41
 Anisha Juneja / A Qualitative Study of Parents’ Reasoning and Decision Making...
1991), expected utility theory (Broome, 1991),
prospect theory and role of affect (Hsee &
Rottenstreich 2004), role of beliefs, values,
behaviour (Hastie & Dawes 2000; Meneghetti
& Seel, 2001) and culture (Hofstede, 1997).
Rational decision making facilitating the
career selection process have been observed
in Krumboltz and Hamel’s model (1977),
Patton and MacMahon’s (2006) systems theory
framework, Parsons (1909) trait and factor
theory, Tversky’s (1972) elimination-by-
aspects model and Herbert Simon’s bounded
rationality concept (1955). Deviations from
the rational process in career selection have
been observed by Harren (1979), Mitchell and
Krumboltz (1990), in terms of collaboration
based decision making with parents acting
as scaffolders to their children (Wood et.al.,
1976).
7KH VLJQL¿FDQW RWKHUV LQ D FROOHFWLYLVW
tradition based India become an integral part
of the self, affecting and being affected by
the day to day life choices we make. The
mushrooming of innumerable coaching centers,
pressure of career making process initiation
from lower classes, increasing competition and
constant bombardment of varied occupational
options complicate the process. As it is, the
nuclearisation of the families with both the
parents working, increased cost of living with
luxuries becoming needs, shrinkage of social
circles due to lack of time are already the stresses
of the couple of today. This when merged with
securing the future of their children, makes
every decision related to the child to be made
cautiously and affecting the mental well being
of the parents (Small & Eastman, 1991; Warner,
2010; Behnke et.al., 2004). There is confusion
(Small & Eastman, 1991; Chen, 2001) as well
as stress leading to ignorance of child’s needs
(Elkind, 2007).
Reviewed literature brings to focus the
parental aspects as perceived by the adolescents
WREHLQÀXHQWLDOIRUFHVRQWKHFKRLFHPDGH7KHUH
is dearth of studies in India that try to understand
the cognitive processes carried out by parents to
arrive at a career choice for the child. The career
42
choice has consequences on the quality of life
RI ERWK WKH SDUHQWV DQG FKLOG ,GHQWL¿FDWLRQ RI
the process will enable the viewpoint of parents
on this issue. Since the decision will require
adjustment from both the parties, thus, mental
health becomes an important concern.
AIM
The aim of the present research is to
understand the parents’ involvement in the
career choice for their child and its mental health
impact.
x
OBJECTIVES
To understand parents’ reasoning process
x
in career choice for their child
To understand parents’ decision making in
x
career choice for their child
To understand impact of process of
making the career choice on mental health
of parents
METHOD
Participants:
20 parents of children enrolled in classes
9th to 12th were selected through snowball
sampling (Biernacki & Waldorf, 1981). Parent
scoring beyond cut off point (3) on GHQ-12
was not selected for the research although no
participant scored beyond the cut off point in the
current study.
Measures:
Socio-demographic Data Sheet:
To get socio demographic information
pertinent to the parent and the child.
General Health Questionnaire 12 (Goldberg
& Williams, 1992):
GHQ 12 was used to screen out respondents
with psychiatric disorders in community setting.
Semi Structured Interview Schedule:
Semi Structured Interview Schedule was
developed based on the review of literature and
brain storming among researchers keeping in mind
the objectives of study. The type of questions, their
wording, the sequence were thought over with the
probes ready to use as and when required. A pilot
study was done to gauge its appropriateness and
 Anisha Juneja / A Qualitative Study of Parents’ Reasoning and Decision Making...
the necessary changes were made henceforth. 7DEOH0DMRU7KHPHVDQG6XE7KHPHV,GHQWL¿HG
The following domains were included in the semi in Reasoning and Career Choice
structured interview schedule:
x
Major theme Subthemes N
)DFWRUVLQÀXHQFLQJSDUHQWV¶FDUHHUFKRLFH Child’s ability or performance in 12
OLA?Eł?OQ>FA?P
x
for the child and for themselves
Child related Parents developing child’s potential to 8
Process of arriving at the career choice for factors decide

x
the child and for themselves
Physical attributes of child 5
Impact of this process on parents’ socio- Individual choice of child 2
occupational-personal functioning and
Birth order of child 1
well being
Change due to learning with elder child 1
Procedure: Parent Financial resources 12
The protocol was presented and cleared related Personal preference of parents 8
by Departmental Review Committee, IHBAS factors
Ethical Review Committee and MPhil Course Future #QHłHHEJCPDAJAA@O EJPANAOPO=J@ 14
related desires of child
Co-coordinating Committee. The study was factors Future role responsibilities especially 7
conducted in two phases: pilot phase and main based on gender
phase. A pilot study was carried out with 2 Easing process of career achievement 3
SDUHQWVLQRUGHUWRUH¿QHWKHWRROXVHG$IWHUSLORW Deductive 10
study changes were made in wording and content Nature of
Inductive 8
of the questions. The data obtained from the reasoning
Conditional 2
participants in the pilot study was not included
LQWKH¿QDOFRGLQJDQGDQDO\VLV7KHPDLQSKDVH
7DEOH 0DMRU WKHPHV DQG 6XEWKHPHV LGHQWL¿HG
included 20 parents. The participants were
selected through snowball sampling method. in decision making and career choice
After introducing the research objectives and Major theme N
obtaining a written informed consent from Rational analytic decision making 11
the participants, GHQ 12 was administered. Non-rational decision making 6
Thereafter, the participant was interviewed for Affect based decision making 3
approximately 40-50 minutes using the semi
structured interview schedule and interview was 7DEOH 0DMRU 7KHPHV DQG 6XE7KHPHV ,GHQWL¿HG LQ
audio recorded. The recorded interview was then Mental Health Impact and Career Choice Process
transcribed for further analysis. Analysis of data
Major theme Subthemes N
was carried out by thematic analysis (Boyatziss,
1998). Relevant and meaningful features and Socio-occupational- Personal routines and
11
personal well-being social life compromised
content of the data were used to generate the
initial codes. The codes were then sorted into Occupational adjustments 8
potential themes by looking at how different Psychological factors Distress 5
codes were combining to form an over arching Confusion 12
theme (Braun & Clarke, 2006). Role responsibility as Providers role 15
parents
RESULTS -NKPA?PERAłCQNANKHA 12
Results of the present study are represented Positive appraisal 2
in major themes and sub-themes in Table 1 to
7DEOH7KH¿QGLQJVDUHSUHVHQWHGXQGHUWKUHH DISCUSSION
headings: Reasoning and career choice, decision Reasoning and career choice: More than
making and career choice, and mental health 50% of parents took child’s past performance in
impact of career choice process. mind for career choice in the present study. Chan

43
 Anisha Juneja / A Qualitative Study of Parents’ Reasoning and Decision Making...
(2005); Sabogal et al., (1995) support the fact
that the child’s ability builds parents’ aspiration
and career choice. Study by Taylor, Harris et al.,
(2004) found that interest as a factor may not be
taken into account. They stated that parents more
pragmatic approach could be giving weightage
to other factors for instance job market in an
aim to maintain balance. In the present study
easy career attainment, higher prestige and
DYDLODELOLW\ RI JXLGDQFH IRU D VSHFL¿F VXEMHFW
greater guarantee of security and future success
were found to be contributing to career choice,
thus, supporting Taylor et al. (2004) assumption.
The literature has suggested that child’s academic
interest is ignored while more emphasis is given
to parental aspirations (Wong et al., 2011) and
differential perception of certain subjects and
professions (Chun, 1995; Chen, 2001; Asher,
despite the limitations (Bandura et al., 2001).
Minimal guidance and leaving the
decision on the individual choice of child was
done by only 2 parents in the present study. This
distancing to the parental perception of career
decision making as something beyond their
control, a trial and error process that the child
should experience himself/herself. Decreased
parental involvement can result in child’s
lower academic involvement,the parents may
be required to be available for developing the
ability of the child to make a fruitful independent
decision (Vygotsky, 1978).
Parental income determines the kind of
academic environment provided to the child
which then effects the nature of aspirations
the child can imagine and his/her achievement
(Davis-Kean, 2005). The present study showed
7KXVWKH¿QGLQJVRIWKHSUHVHQWVWXG\DUH
unfortunately in sync with the literature. Ideally
speaking child’s academic interest need to be
the primary criteria for the career choice, for it
hypothesized to lead to a better quality of life in
the long run for an individual. Although, in the
present study the number was small (40%) but it
was positive to note that there were parents who
were building child’s potential to decide career
FKRLFHD¿QGLQJJHWWLQJDQHFKRLQWKHOLWHUDWXUH
too (O’Briend et al., 2003; Taylor et al., 2004).
Professions have certain physical characteristics
criteria engineered by the society (English et
al., 2011). In the present study, despite the fact
that the physical attributes of the child did not
match with the professional choice, parents were
hopeful. Also there were parents who understood
the physical limitations but wanted their children
to overpower them by developing greater mental
prowess and professional position. Lent et al.
(2000) social cognitive theory extrapolated
by Albert and Luzzo (1999) in the career
domain explained that even though physical
imperfections are seen as a career barrier, they
may not just constrain but also enhance personal
agency in career decision making. Thus, the
physical attributes may be restraining in some
way but the parental aspirations may enhance the
FKLOG¶VVHOIHI¿FDF\DQGRFFXSDWLRQDODVSLUDWLRQV
44
PL[HG ¿QGLQJV LQ WHUP RI VRPH SDUHQWV OHWWLQJ
¿QDQFHV OLPLW WKH FDUHHU FKRLFH DQG SDUHQWDO
academic aspirations whereas some parents
SULRULWL]LQJ FDUHHU FKRLFH RYHU ¿QDQFLDO
limitations. The literature has also seen mixed
results (Bandura, 2001; Singh-Manoux et al.,
2006; Sewell & Shah, 1968). Parents act as
UROH PRGHOV LQÀXHQFH FKLOGUHQ¶V VHOIFRQFHSW
become occupational motivators, and provide
job information (Pappas & Kounenou, 2011)
and in the process develop similar attitudes in
the children too (Chen, 2001). The participants
in the present study were also seen involved
in the same process. The participants also kept
in mind the future related factors in terms of
D FDUHHU FKRLFH IXO¿OOLQJ WKH QHHGV LQWHUHVWV
and desires of the child so that it could be
less struggling for them as compared to the
participants own childhood (Taylor et al., 2004;
Saiti & Mitrosilli, 2005). The present study
participants also reported gender career typing
(Reiss et al., 1995; Hill et al., 2003; Turner et
al., 2004). They believed female should take up
a role which gives the female enough time at
home to look after her family as well. Another
¿QGLQJ HPHUJHG LQ WKH VWXG\ VKRZHG SDUHQWV
kept the family work option open to ease the
career achievement of the child and prevent him/
her from facing the hardships of an increasingly
 Anisha Juneja / A Qualitative Study of Parents’ Reasoning and Decision Making...
competitive world where the child’s entry in decision and henceforth the parent comes in to
a reputed college is not guaranteed (Warner, take the decision on child’s behalf (Bandura,
2010). 1997). Involvement of affect, an emotion based
The participants followed different decision making in career decisions led only 3
nature of reasoning. In the deductive process parents to mould their communication patterns in
participants were trying to arrive at a choice a way such that the child would himself/herself
empirically through the evidence of certain choose the option thought by parent. Family’s
factors if not all, that supported their choice FDUHHU GUHDP EHFRPHV D SRZHUIXO LQÀXHQFH
of career for the child. Inductive reasoning on career decisions of the child (Blustein,
was observed in the form of 8 parents not 2001; Chen, 2005; Okubo et al., 2007). Career
pressurizing the child for academic excellence achievement in child’s life can be used as a tool
because the child was physically weak during to overcome the dissatisfaction in parental lives
childhood, or parents making the child choose making families unable to process the factors that
a stream because they had resources in terms of were clearly indicative of the child’s inability
JXLGDQFHIRUWKDWYRFDWLRQRUWKHDXWKRULW\¿JXUH WRIXO¿OWKHFULWHULDRIDSDUWLFXODURFFXSDWLRQDO
believing self to be the best decision maker. The choice.(Sewell & Shah, 1968).
conditional reasoning parents were using an if- According to Harren’s (1979) taxonomy
then argument with child to convince the child of decision making style then, the non rational
for the option parents themselves had thought decision makers were taking an intuitive
of. Only if the child could secure a position in approach to decision by either making decisions
reputed college, could he/she go in for a career based on feelings and emotional satisfaction or
choice of his/her own. Therefore both ways, the making decisions based on expectations and
chances of success in one would enhance the opinions they had about the options. At times,
probability of occurrence of the other event. the unexplained nature of career decision
SURFHVVUHVXOWHGLQFRQÀLFWVEHWZHHQWKHSDUHQW
Decision making and career choice: or child or on the other hand led the child to be
Coming onto the second process, decision completely free to decide without providing
making, under consideration, a rational route to him/her the parental guidance. These parents
decision making was taken by 11 participants may be driven by prospect theory of decision
by generating alternatives, evaluating the making wherein, decisions get value based
desirability and feasibility of each option and on the amount of gain and loss incurred the
then selecting the best one appropriate as the principle psychological accounting. Parents get
¿QDO RSWLRQ 7KHVH SDUWLFLSDQWV ZHUH IRXQG LQÀXHQFHGE\KRZWKHDOWHUQDWLYHVJHWIUDPHGRU
to follow Super’s (1990) model of career presented in media (Bright et al., 2004). Despite
development and Krumboltz and Hamel (1977) the fact that the career decision making process
DECIDES model and (Bright et al., 2005). As is a complex developmental task (Gati et al.,
highlighted by Parsons (1909) trait and factor 1996) but some parents in the present study did
theory, some participants made a connection not exert required careful thought and plan.
between the person’s interests, abilities and
resources to the career choices. Deviating from Mental Health and Career Choice:
the rational route, some participants were taking There is dearth of literature addressing
the decision for the child being the authority how the career decision making task affected
¿JXUHV D FRXSOH RI WKHP EHLQJ H[SOLFLW LQ parents’ socio-occupational-personal well-
enforcing the decision despite seeing the child being. The affects were observed in the form of
voicing an opposite opinion. The child may not personal routines and social life compromised
be perceived capable of making the appropriate in terms of less and delayed sleep, decreased

45
 Anisha Juneja / A Qualitative Study of Parents’ Reasoning and Decision Making...
socialization and restriction in home activities.
Occupational adjustments were observed in
some participants. They disclosed that since the
higher secondary education period was a crucial
point of time in the child’s career when his/her
future gets decided, it was the priority of the
parents to look after the child’s needs than to be
involved in their own professional lives. They
started working hard or not taking promotions or
even quitting work completely. This is supported
by Schneider and Lee’s (1990) study that
highlighted that child’s academic achievement
is viewed as the most important pursuit in the
parental lives.
Distress and confusion in participants
in terms of experiencing excessive demands
on their physical and mental resources were
involved in the child’s upbringing. The changes
in the parents’ own lives, affecting their sleep-
wake patterns, socialization, restrictions in
taking leave from work to save on money
and restrain from spending on them made the
process a highly demanding one. The variety of
career options and technological advancements
PDGHWKHSDUHQWVTXHVWLRQWKHLURZQHI¿FLHQF\
in taking a crucial decision as this decision
would determine the future of the child. The
increasing competition, limited number of
good universities and social isolation is placing
pressure on the parents who in turn pressurize
the children to clear the entrance exams for
various such universities.
The career decision making task was taken
as a role responsibility to act as providers to
the child, giving the children an environment
to study, materials to study and let the child
perform his/her role of student without any
external burden. Findings of Schneider and Lee
(1990) and She and Suzhen (1992) also mention
the household responsibility taken over by the
parents completely so that the children are not
disturbed. In the present study, the process
of making the child perform his/her student
role was at times be accompanied by parental
instructions to limit or control the child’s outdoor
activities or social circle. Schneider and Lee
(1990) also bring to notice the efforts of parents
46
of Asian students in structuring the child’s out of
school time so as to direct the child to academic
related skills development. Very few parents
were able to adopt positive appraisal of the role
responsibility experienced due to the child’s
career decision making process. They reported
that their social life had increased resulting in
increase in knowledge. There were parents
DFWLQJDVDSURWHFWLYH¿JXUHWRWKHFKLOGPDNLQJ
an effort to provide to the child the things that
they missed and required in their own childhood
through their parents like education, stable
DFDGHPLF DQG KRPH HQYLURQPHQW ¿QDQFLDO
resources, facilities and opportunities to have a
successful and easy future for the child even if
it is accompanied by lack of knowledge about
the child’s own academic aspirations (Sabogal
et al., 1995).
The present study has its own limitations.
The sampling technique does not result in true
representation of the population. Being dependent
RQVRFLDOQHWZRUNRIWKH¿UVWUHVSRQGHQWSRSXODU
UHVSRQGHQWV DUH OLNHO\ WR ¿QG SODFH LQ VWXG\
Being subject to sampling bias, the study also is
restricted to largely studying mothers residing
in metro city. The study being in qualitative
mode is on the one hand informative but is low
on generalizability to a larger population. With
respect to future research suggestions, perspective
of the father, the difference in the opinions of the
parents with a larger sample size and correlating
parental reports with the experiential report of the
child under consideration for the career decision
may be made.
CONCLUSIONS
The study emphasizes the complexity of
the developmental task of making a career choice
DQG LWV LPSDFW RQ PHQWDO KHDOWK 7KH ¿QGLQJV
revealed that people follow, without being
aware of it, psychological principles in life’s
major decisions. Assessing the lack of research
in this area in India the present study could help
to bring in focus a neglected area/an area which
is exploited through inappropriate behaviours by
different parties leaving the parents and children
helpless.
 Anisha Juneja / A Qualitative Study of Parents’ Reasoning and Decision Making...
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Indian Journal of Clinical Psychology Copyright, 2013 Indian Association of
2013, Vol. 40, No. 1, 49-54 Clinical Psychologists (ISSN 0303-2582)
Research Article
Burden of Care and Expressed Emotion in Spouses of Chronic
Schizophrenic Patients
Sandhyarani Mohanty1 and Sudhir Kumar2

ABSTRACT
Expressed Emotion (EE) is one of the critical factors that has been implicated in the relapse of
major psychiatric disorders. Less attention has been paid to the antecedent factors that contribute
to EE in family members. The present study was designed to explore the role of Burden of
Care and selected demographic and clinical variables in Expressed Emotion of spouses of
chronic schizophrenic patients. Burden Assessment Schedule and Family Attitude Scale were
DGPLQLVWHUHGRQVSRXVHVRIFKURQLFVFKL]RSKUHQLFSDWLHQWV7KHUHVXOWVUHYHDOHGDVLJQL¿FDQW
correlation between Burden of care and expressed emotion. Medicine compliance and expressed
HPRWLRQ ZHUH DOVR IRXQG WR EH VLJQL¿FDQWO\ DVVRFLDWHG LQ PDOH VSRXVHV7KHUH LV D QHHG IRU
addressing the burden of care not only for its direct relevance for the caregivers but also for
mitigating the probability of relapse in major psychiatric disorders.
Key Words: Expressed Emotion, Burden of Care, Schizophrenia, Family of Schizophrenic Patients.

INTRODUCTION: Brown, & Rutter, 1966; Karno et al., 1987; Vaughn

The construct of EE (expressed Emotion) is & Leff, 1976). Kavanagh (1992) by analyzing 26
designed to capture the emotional climate’ within published studies of schizophrenic patients on
a family. It comprises of criticism, hostility, and EE reported that in high-EE families the mean
emotional over-involvement (EOI). The seminal relapse rate was 48% and it was only 21% in
work on EE was done by George Brown in 1950s. low EE families. Bebbington and Kuipers (1994)
He observed that many stable schizophrenic analyzed data of 1,346 patients and demonstrated
patients who were discharged returned and got a relationship between EE and relapse. High
re-admitted due to symptom relapse. Along with levels of EE robustly predict higher relapse rates.
his colleagues, he planned a systematic study to A meta-analysis found that across 27 studies, the
understand the symptom relapse by recruiting mean effect size of the EE-relapse relationship was
229 men who were discharged from psychiatric r=.31 (Butzlaff & Hooley, 1998)
hospitals. 156 of them had a diagnosis of It is postulated that high EE attitude creates
schizophrenia (Leff, 2000). They observed a link a stressful environment for the patients which
between relapse and the type of home environment produce high arousal level compared to the
to which the patients returned after discharge. The patients with low-EE environment (Leff, 1985).
patients who stayed with their parents and wives Tarrier et al., (1988) and Tarrier and Turpin (1992)
after discharge were more likely to relapse and observed that patients were having higher levels
get re-admitted than those who lived in lodgings of arousal in the presence of a high-EE relative
or with their siblings. It was suggested that the than a low-EE relative. Leff (1985) reported that
IDPLO\HQYLURQPHQWPD\KDYHDQLQÀXHQFHRQWKH off medication patients were more susceptible to
conditions of the patients. relapse if they were either living with a high-EE
/DWHU UHVHDUFKHUV IXUWKHU FRQ¿UPHG WKDW parent or experiencing a stressful life event. He
critical and emotionally over-involved attitude proposed that these factors cause stress, which
of family members negatively affect the persons creates a rise above the optimal level of arousal in a
with schizophrenia (Bebbington & Kuipers, 1994; patient. Cutting and Docherty (2000) observed that

5HVHDUFK2I¿FHU'LUHFWRU,QVWLWXWHRI0HQWDO+HDOWKDQG+RVSLWDO$JUD±
Corresponding Address - Email: imhh.agra@gmail.com

49
 Sandhyarani Mohanty / Burden of Care and Expressed Emotion in Spouses of Chronic...
SDWLHQWV UHFRXQWHG D VLJQL¿FDQWO\ JUHDWHU QXPEHU
of ‘stressful’ memories about high-EE parents than
low-EE parents lending support to this hypothesis.
The precise reasons why some caregivers
have high-EE are yet to be established. The
UHVHDUFKHUV KDYH LGHQWL¿HG UHODWLRQVKLS RI
personality traits of caregivers with EE. Hooley
and Hiller (2000) reported caregivers’ personality
traits; reduced satisfaction of individual activities,
reduced optimism about future, and reduced self-
HI¿FDF\ KDYLQJ VLJQL¿FDQW DVVRFLDWLRQ ZLWK ((
Leff (1985) stated that if a caregiver is usually
tense or irritable during stressful situations, this
stress can result in feelings of anger. Scazufca and
Kuipers (1996) observed that EE and the burden of
care are related. In an Indian study, Nirmala et al.
(2011) found no relationship between caregivers’
burden and level of expressed emotions by the
patients with schizophrenia. Metwally et al. (2008)
IRXQG WKDW WKHUH ZHUH KLJKO\ VLJQL¿FDQW SRVLWLYH
correlations between expressed emotion, family
burden and stigma of mental illness.
The knowledge and attribution of patients’
illness by the caregivers also contribute to EE. The
FRQWUROODELOLW\ DWWULEXWLRQ LV LGHQWL¿HG DV WKH NH\
attribution style affecting caregivers EE. High-
criticism caregivers are more likely to believe that
patients can have control over the manifestation
of their symptoms than low-criticism parents
(Barrowclough et al., 1994; Hooley, 1987). The
guilt feelings induced in caregivers by the beliefs
that they might have contributed to the patient’s
problems (Bentsen et al., 1998; Chambless et al.,
2001) in some way, might lead to the behaviors that
are characteristic of high EE. A tendency to wish
to control the patient’s behavior may be another
variable that underlies high EE (Hooley, 1985).
The stress and attribution style of caregivers
have been demonstrated to have a link with EE in
caregivers. Schene (1990) hypothesized that the
chronic illness of a family member is an objective
stressor that results in strain for the family
caregiver because of the care giving role.
This model can be extended to implicate a
two way process. That is, the chronic illness in
a patient creates stress in a caregiver (Schene,
50
1990) leading to emotional reactions like anger
(Leff, 1985) which in turn creates stress and
hyper-arousal in the patients (Tarrier et al., 1988;
Tarrier and Turpin, 1992; Leff, 1985) producing a
propensity to relapse and setting up the stage for a
vicious cycle.
There are ample evidences that indicate
role of EE in causing relapse in schizophrenic
patients. The researches on the other aspect of
the above model regarding a link between stress
of family members and EE are relatively less and
even contradictory. Scazufca and Kuipers (1996)
and Metwally et al. (2008) observed a positive link
between caregivers’ burden and EE whereas the
Indian study by Nirmala et al. (2011) failed to have
any association between burden and EE.
The present study was designed to address
the contradiction by exploring the relationship
between caregivers’ stress and EE. Additionally,
most studies on EE focused on caregivers in
general; the present study, on the other hand,
ZDV GHVLJQHG WR VSHFL¿FDOO\ IRFXV RQ (( LQ
married couples by taking caring spouses as the
respondents.
Hypotheses:
It was hypothesized that burden of care is
VLJQL¿FDQWO\DVVRFLDWHGZLWKH[SUHVVHGHPRWLRQLQ
spouses of persons with chronic schizophrenia:
In addition to above hypotheses, the study
was also planned to explore if select socio-
demographic and clinical variables have any
bearing on expressed emotion in the spouses of
chronic schizophrenic patients.
METHOD:
Design:
This is a cross-sectional correlational study
conducted at Institute of Mental Health and
Hospital, [IMHH], Agra.
Sample:
IMHH, Agra is a tertiary care psychiatric
hospital. Family Ward of the Institute is an open
short stay ward in which the family members stay
with their patients for about 15 days. The intake
capacity of the ward is 60 patients. The spouses
of chronic schizophrenic patients presenting at
 Sandhyarani Mohanty / Burden of Care and Expressed Emotion in Spouses of Chronic...
Family Ward of IMHH, Agra for treatment of their the family member’s amount of criticism and
ill patients constituted the study population. 40 hostility. Its psychometric characteristics are
chronic schizophrenic patients and their spouses reported in parents of undergraduate students
were recruited in the sample based upon following and in 70 families with a schizophrenic member.
inclusion/exclusion criteria. The total FAS had high internal consistency in all
samples, and reports of angry behaviour in FAS
Criteria for the Patients: items showed acceptable inter-rater agreement.
1. The schizophrenic patients who met
Hostility, high criticism and low warmth on
diagnostic criteria of ICD-10.
the Camberwell Family Interview (CFI) were
2. Two years continuous schizophrenic illness associated with a more negative FAS. The highest
in the patients. FAS in the family was a good predictor of a highly
3. Age of the patients in the range of 25-55 critical environment on the CFI. The FAS is a
years. reliable and valid indicator of relationship stress
4. Patients with history of regular substance and expressed anger that has wide applicability.
abuse except tobacco were excluded RESULTS:
5. Patients with co-morbid affective disorder, Table-1 : Characteristics of Patients and Spouses
mental retardation, organic involvement Patients Characteristics
were excluded
Attributes Male Female
Criteria for the Spouses: Patients Patients
1. Duration of stay with the patient for at least No. of participants (N) 21 19
two years Age (in years) Mean±S.D. 40.85±7.74 36.57±6.53
2. Absence of major psychiatric and medical Education (in years) Mean±S.D. 5.71±5.01 4.47±3.80
illness; substance abuse, mental retardation. Working 08 10
Occupation
Not working 13 09
Tools Administered:
Rural 10 09
Personal Data Sheet: This was used to Domicile
record demographic characteristics of patients and Urban 11 10
spouses and clinical data regarding the patients. Socio-economic Middle 11 10
Status Low 10 09
Burden Assessment Schedule (BAS):
Duration of illness (in years) 8.90±6.07 7.89±5.11
Burden Assessment Schedule (BAS) was Mean±S.D.
developed and standardized by Thara et al (1998) Spouses’ Characteristics
through step wise ethnographic exploration
Attributes Male Female
method. There are 40 items rated on three points Spouses Spouses
scale. BAS is the most frequently used tool to No. of participants (N) 19 21
assess the burden of care of psychiatric patients
Age (in years) Mean±S.D. 40.52±7.69 36.57±7.45
in India. The inter rater reliability is high (Kappa:
0.80). It has high content validity. Criterion Education (in years) Mean±S.D. 4.95±4.17 2.00±4.29
validity was established by comparing with the Occupation Working 03 11
Family Burden Schedule (Pai & Kapur, 1981) – Not working 16 10
values ranged between 0.71-0.82. Duration of exposure to spousal 7.42±5.28 8.85±6.13
illness (in years) Mean±S.D.
Family Attitude Scale (FAS):
This scale was generated on the basis of Burden and Expressed Emotion:
existing questionnaires, the EE literature, and the The mean, S.D. of Burden Assessment
know-how of experienced clinicians (Kavanagh et Schedule (BAS) scores and Family Attitude Scale
al 1997). It is a 30-item instrument that assesses (FAS) scores are presented in following table.

51
 Sandhyarani Mohanty / Burden of Care and Expressed Emotion in Spouses of Chronic...
7DEOH0HDQ6' &RUUHODWLRQ&RHI¿FLHQW
of BAS and FAS Scores
BAS Scores FAS Correlation
Scores KABł?EAJP
Total Sample 87.92±19.79 47.72±10.74 .529 P<.001
(n=40)
Males (n=19) 83.57±20.64 48.89±10.49 .692 P<.001
Females (n=21) 91.85±18.61 46.66±11.11 .454 P<.05
7DEOH UHYHDOV VLJQL¿FDQW FRUUHODWLRQ FR
HI¿FLHQWEHWZHHQ%$6VFRUHVDQG)$6VFRUHVLQ
total sample as well as in both the genders.
To detect the role of socio-demographic and
illness related variables in expressed emotion, a
stepwise regression was performed by processing
following variables as the predictors – Patients’
age, Duration of Illness, No. of Hospitalizations,
Spouses’ age, Spouses’ working status, Spouses’
education, Family type, Duration of exposure
to spousal illness and medicine compliance.
This analysis resulted in retention of only
0HGLFLQH &RPSOLDQFH YDULDEOH DV WKH VLJQL¿FDQW
predictor with an R2 of .148 P<.01. The medicine
compliance was dichotomized into regular and
irregular compliance. An inverse relationship
between medicine compliance and expressed
emotion was observed; r=-.385 P<.01.
A further gender based sub-group analysis was
performed for estimating the correlation between
medicine compliance and expressed emotion. An
DISCUSSION
Burden and Expressed Emotion:
7KH EXUGHQ RI FDUH LQ VSRXVHV LV UHÀHFWHG
in the total mean score which is very high
indicating a considerable burden in the caring
spouses of schizophrenic patients. There is an
extensive literature on the burden in caregivers of
schizophrenia including the spouses (Martens &
Addington, 2001; Lowyck et al., 2004; Nizhawan
et al., 1985; Kumar et al., 2001; Kumar et al., 2002;
Kumar et al., 2005; Kumar & Mohanty, 2007). The
results of burdens are in expected direction and
support the existing literature.
The focus of the present study was to explore
to what extent this burden of care contribute to
expressed emotion in the spouses of schizophrenic
patients. The results of the correlation between
burden and expressed emotion measure indicate a
VLJQL¿FDQWO\KLJKDQGSRVLWLYHFRUUHODWLRQEHWZHHQ
these two variables. The results were further
examined in relation to the genders of the spouses
by correlating burden and EE measures separately
LQWZRJHQGHUV7KHUHVXOWVUHYHDOHGDVLJQL¿FDQW
positive correlation between the measures in both
the genders. These results indicate that burden of
FDUH VLJQL¿FDQWO\ FRQWULEXWH WR (( LQ VSRXVHV RI
both the genders.
The results of positive link between burden and
EE are in expected direction and support previous
LQWHUHVWLQJ ¿QGLQJ ZDV REVHUYHG WKDW PHGLFLQH
compliance and expressed emotion were having
D VLJQL¿FDQW QHJDWLYH UHODWLRQVKLS RQO\ ZKHQ WKH
spouses were male; r=-.572 P<.01. The value of
FRUUHODWLRQLQIHPDOHVXEVDPSOHZDVQRWVLJQL¿FDQW
r= -.208 P>.05. This result indicates that male
VSRXVHVKDYHVLJQL¿FDQWO\KLJKHU((IRUWKHLUIHPDOH
ill spouse in case of poor medicine compliance.
,QYLHZRIVLJQL¿FDQWUHODWLRQVKLSEHWZHHQ
medicine compliance and expressed emotion, it
was further explored if medicine compliance has
any bearing on burden of care and consequently
affecting the expressed emotion. A negative
EXW QRQVLJQL¿FDQW FRUUHODWLRQ FRHI¿FLHQW ZDV
detected between BAS scores and medicine
compliance; r= -.159, P>.05; indicating that
PHGLFLQH FRPSOLDQFH KDV LWV RZQ LQÀXHQFH RQ
expressed emotion independent of burden of care.
52
¿QGLQJV 0HWZDOO\ HW DO  DOVR UHSRUWHG
VLJQL¿FDQW FRUUHODWLRQ EHWZHHQ EXUGHQ DQG ((
Scazufca and Kuipers (1996) reported that high-EE
relatives had considerably higher mean scores for
burden of care then low-EE relatives and perceived
PRUH GH¿FLWV LQ SDWLHQWV¶ VRFLDO IXQFWLRQLQJ WKDQ
low-EE relatives. Patients’ psychopathology was
not associated with EE levels and burden of care.
Their study demonstrated that EE and the burden
of care are related. EE and burden both measure
aspects of the relationship between relatives and
patients. EE and burden of care are more dependent
on relatives’ appraisal of the patient condition than
RQSDWLHQWV¶DFWXDOGH¿FLWV
The burden of care is a recognized stress
factor associated with care giving of psychiatric
patients. The burden could be objective which
indicates effects of illness on the household such
 Sandhyarani Mohanty / Burden of Care and Expressed Emotion in Spouses of Chronic...
DVHIIHFWVRQKHDOWK¿QDQFLDOORVVDQGGDLO\FKRUHV
and the burden could also be subjective which
indicates the extent to which a caregiver perceives
burden. Burden of care places extra-demands on
the caregivers, causes reduction in inter-personal
relationships and social involvement, restrictions
LQ DFWLYLWLHV ORDG RQ ¿QDQFLDO UHVRXUFHV 6LQFH
schizophrenia is a chronic illness with periodic
H[DFHUEDWLRQVDQGGH¿FLWVLWLVDOVRDVVRFLDWHGZLWK
mental health and emotional issues in the caregivers.
The burden as a contributory factor to
H[SUHVVHG HPRWLRQ ¿WV ZHOO LQWR WKH K\SRWKHVLV
that the chronic illness in a patient creates stress
in a caregiver (Schene, 1990) which adds to the
emotional reactions like anger (Leff, 1985) which
is a primary constituent of EE and this expression
of anger emotion towards patient creates stress
and hyper-arousal in the patient (Tarrier et
al., 1988; Tarrier & Turpin, 1992; Leff, 1985)
which is responsible for producing a propensity
towards relapse and that could initiate a vicious
cycle of burdenÆEEÆRelapse. However, this
formulation need be explored and studied further
by methodologically sound prospective studies.
In addition to burden other antecedent variables
FRQWULEXWLQJWR((DOVRQHHGWREHLGHQWL¿HGDQG
examined to postulate a comprehensive and multi-
factorial model of EE.
Since burden and EE are positively
correlated, a change in the level of burden should
result in a corresponding change in EE levels.
This issue was examined by Scazufca and Kuipers
(1998). They observed that a change in EE is
associated with a change in circumstances and
burden. They favored an integrative model of
understanding EE. Since, a reduction in burden of
care has potentials to decrease EE; which in turn
might reduce the relapse and promote maintenance
of treatment gains; it may be recommended that
strategies should be adopted to address the care
givers burden along with core treatment of the
persons with schizophrenia.
Having examined the issue of burden
and EE, an attempt was made to identify socio-
demographic and clinical correlates of EE. Out of
an array of variables only one variable – Medicine
&RPSOLDQFH ZDV IRXQG WR EH VLJQL¿FDQWO\
53
associated with EE. An inverse relationship
between medicine compliance and expressed
emotion was observed. A deeper level of analysis
further revealed that medicine compliance and
(( ZHUH DVVRFLDWHG VLJQL¿FDQWO\ RQO\ LQ PDOH
spouses. This relationship of compliance and EE
were independent of burden of care. Instead, it has
a direct contribution to EE; that too when spouse
is male and patient is female. The male spouses
tend to have more EE when there is low or no
medicine compliance by their female patients. This
¿QGLQJRSHQVDYHQXHVIRUIXUWKHUUHVHDUFKIRUWKH
FRQ¿UPDWLRQ RI WKH ¿QGLQJV RI WKH SUHVHQW VWXG\
as well as for delineation of the factors associated
with EE in male spouses.
CONCLUSION:
Expressed Emotion is considered a
VLJQL¿FDQW YDULDEOH FRQWULEXWLQJ WR WKH UHODSVH LQ
major psychiatric disorders. There may be ethnic
and cultural variations in the expressed emotion.
There is little known authoritative work on the
magnitude of expressed emotion in the families of
psychiatric patients in India. The observations do
indicate presence of EE in families of psychiatric
patients. The present study examined the issue
of what contributes to the EE in spouses of
schizophrenic patients. Socio-demographic and
clinical characteristics in general and burden of
care in particular were examined as determinants
of EE. The results clearly indicates positive
association of burden of care and EE in spouses
of chronic schizophrenic patients but only one
of the other variables – medicine compliance
was found to add to the EE in the spouses. It is
proposed that a model of burden, EE and relapse
could be examined through further researches
LQ DGGLWLRQ WR LGHQWL¿FDWLRQ RI RWKHU DQWHFHGHQW
factors contributing to the EE. Also it is felt that
the spousal burden should also be addressed along
with core treatment of the patients to mitigate
burden and thereby decreasing EE and possibly
the relapse.
REFERENCES:
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of expressed emotion in schizophrenia: an aggregate
analysis. Psychological Medicine, 24, 07–718.
Bentsen, H., Notland, TH., Munkvold, O., Boye, B., &
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Ultsein, I., & Bjorge, H. et al. (1988). Guilt proneness
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Butzlaff, R L., & Hooley, J M. (1998). Expressed emotion
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schizophrenia. Journal of Indian Academy of Applied
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Psychiatry. 3, 72 – 82.
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In: Harris T, editor. Where Inner and Outer Worlds
Meet: Psychosocial Research in the Tradition of George
W Brown. London: Routledge. 97–100.
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& Peuskens, J. (2004). A study of the family burden
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54
Indian Journal of Clinical Psychology Copyright, 2013 Indian Association of
2013, Vol. 40, No. 1, 55-59 Clinical Psychologists (ISSN 0303-2582)
Research Article
Attitude towards Mental Illness among Students Appeared in the
Entrance Examination for Higher Degree in Mental Health
Sujit Kumar Mishra1, Sijo George2, Archana Singh3, K S Sengar4 and Amool R. Singh4

Abstract:
The study was planned to investigate attitude towards mental illness among students seeking
admission in various discipline, appeared in entrance examination at Ranchi Institute of Neuro-
Psychiatry and Allied Sciences (RINPAS) for pursuing their higher degree in Psychiatry,
Clinical Psychology and Psychiatric Social Work (PSW). The purpose of the study was to
¿QGRXWWKHNLQGRIDWWLWXGHVWXGHQWVKDGWRZDUGVPHQWDOLOOQHVVHVLVSULRUWRWKHLUWUDLQLQJLQ
WKH¿HOGRIPHQWDOKHDOWKDQGGLIIHUHQFHVLQSHUFHSWLRQDPRQJGLIIHUHQWJURXSV7KHVDPSOH
size was consisted of 180 randomly selected students (20 Psychiatry, 135 Psychology and 25
PSW) who were selected through purposive random sampling technique. A semi-structured
VRFLRGHPRJUDSKLFGDWDVKHHWDQG$WWLWXGH6FDOHIRU0HQWDO,OOQHVV$PRGL¿HGYHUVLRQRI
the questionnaire, Opinions about Mental Illness in the Chinese Community (OMICC) (Ng
& Chan, 2000) were used to collect the relevant information. Results of the study showed
VLJQL¿FDQW JURXS GLIIHUHQFHV LQ VWHUHRW\SLQJ SHVVLPLVWLF SUHGLFWLRQ DQG VWLJPDWL]DWLRQ
domains of the attitude towards mental illness where the attitude of the psychiatry group
towards mental illness was better than the other two groups.
Key Words: Attitude, Mental Illness, Mental Health

INTRODUCTION that presentation of mentally ill people as

Mental illness is the term used to describe a
broad range of mental and emotional conditions.
Even though mental illness affects many people
around the world, mental illness unlike other
chronic physical illness is associated with a
number of misunderstandings and myths. For
example, it is common for people to assume
that mental illness is caused by moral weakness
and/or is in the possession of evil spirits. In
addition, mental illness is often associated
with dangerousness and violence (Phelen et
al., 2000; Pescosolido et al., 1999). According
to Corrigan (2004) people often segregate the
mentally ill from the rest of society thinking
they are dangerous and violent. This attribution
of mentally ill with dangerousness and violence
is very often due the portrayal of mentally
ill people as violent and dangerous on the
media. It was argued by Hyler et al. (1991)
dangerous and violent have been so frequent in
¿OPVWHOHYLVLRQQRYHOVDQGFRPLFVWKDWSHRSOH
accept them without a second thought. Due to
the misunderstanding and myths surrounding
mental illness, mentally ill are sometimes
stigmatized and may be labeled in stereotypical
names such as ‘madman’, ‘morons’, ‘lunatics’,
‘maniacs’ and ‘psycho’ (Kaminiski & Harty,
1999). In some instances mentally ill may be
denied of human rights. They are discriminated
in society on necessities of everyday living
like communicating with others, employment,
proper food, decent clothing and housing.
The most devastating and frightening
experience the mentally ill has to undergo
is isolation and loneliness. People tend to
seclude the mentally ill from others. Once
institutionalized, many families refuse to take
back their mentally ill family members even

1. Psychiatric Social Worker, 5HVHDUFK2I¿FHU3V\FKLDWULF6RFLDO:RUNHU'HSDUWPHQWRIPSW 4. Additional Professor,

Department of Clinical Psychology, 5. Director, Ranchi Institute of Neuro Psychiatry and Allied Sciences (RINPAS), Kanke,
Ranchi (Jharkhand), India.

55
 Sujit Kumar Mishra / Attitude towards Mental Illness among Students Appeared in the...
after recovery from the illness, forcing these
already miserable people to totally lose trust
in others and their condition takes a turn back
into its worse. Apart from the above, mentally
ill are also harassed and tortured in ways like
chaining them down so that they cannot move
DQG LQÀLFWLQJ RWKHU ERGLO\ SDLQ DQG KDUP7KH
stereotypical labeling of the mentally ill becomes
so permanent that the person is stigmatized with
the stereotypical names even after recovering
form the illness. People fail to understand their
capabilities because of an unfortunate illness
they encountered and are refused jobs for which
WKH\DUHTXDOL¿HG7KLVPDNHVLWGLI¿FXOWIRUWKH
recovered mental patients to pull themselves
up and gain a level of independence in the
community (Huxley, 1993).
The study of public attitudes toward
mental illness and persons with mental illness
has mostly been the domain of mental health
professionals. This area of research was of
¿QLWHLQWHUHVWWRSXEOLFRSLQLRQDQDO\VWVODUJHO\
because the issue had little public resonance until
quite recently. Before the late 1960s and early
1970s a period when many patients in mental
institutions were deinstitutionalized, the topics
of mental health in general and persons with
mental illness in particular also were of limited
concern to the public. Mental illness was an area
most often treated by individuals and families
as a “private matter” that was more or less off-
limits to outsiders, except, perhaps, medical
professionals and other family members. It is,
therefore, important to understand people’s
attitude towards mentally ill and possible factors
which might have lead to the formation of
these attitudes. It is very likely that a person’s
EDFNJURXQG DQG H[SHULHQFH PD\ LQÀXHQFH KLV
her attitude towards mentally ill.
Although, several studies have been carried
RXWWR¿QGRXWWKHDWWLWXGHWRZDUGVPHQWDOLOOQHVV
among college students, medical students,
community sample, general population etc. but
so far no study is there which would have shown
the attitude of students from various discipline
56
who are preparing to pursue their higher
degree in mental health. Therefore, the present
VWXG\ZDVFDUULHGRXWWR¿QGRXWWKHDWWLWXGHRI
students towards mental illness who appeared
in entrance examination at Ranchi Institute
of Neuro-Psychiatry and Allied Sciences for
pursuing higher degree in Psychiatry, Clinical
Psychology and Psychiatric Social Work.
MATERIAL & METHOD
This cross-sectional study was carried out
at the Ranchi Institute of Neuro-Psychiatry and
Allied Sciences (RINPAS), Ranchi. A total of
180 students (20 for MD & DPM in Psychiatry,
135 for M.Phil & Ph.D in Clinical Psychology
and 25 for M.Phil & Ph.D in Psychiatric Social
Work) appearing in the entrance examination to
pursue their higher degree in different discipline
in mental health were taken consecutively for
the study.
Assessment:
Relevant socio-demographic data was
collected with the help of a semi-structured socio-
demographic data sheet. Attitude was assessed
with the help of Attitude Scale for Mental
,OOQHVV$PRGL¿HGYHUVLRQRIWKHTXHVWLRQQDLUH
Opinions about Mental Illness in the Chinese
Community (OMICC) (Ng & Chan, 2000).
This scale is consisted of 34 items which are
further divided into six domains i.e. separatism,
stereotyping, restrictiveness, benevolence,
pessimistic prediction and stigmatization. Each
item was rated on the basis of totally disagree,
sometimes agree and totally agree. It has been
proven to have good inter-rater reliability and
validity (face, content and criterion).
Data Analysis:
Data analysis was done with the help of
Statistical Package for Social Science (SPSS
16.0).
RESULTS
Attitude of people towards mental health in
general and mental illness in particular has been
a matter of concern for many years. Through the
various available literatures it is also obvious
 Sujit Kumar Mishra / Attitude towards Mental Illness among Students Appeared in the...
that different people have different opinion about Table 2: Group Difference in Attitude towards
mental illness. Therefore, the present study was Mental Illness:
conducted at RINPAS on those candidates who Groups
had appeared in the entrance examination in Domain
Psychiatry Psychology PSW
RUGHU WR SXUVXH WKHLU KLJKHU GHJUHH LQ WKH ¿HOG
of mental health. Separatism
Totally Disagree 48 % 41.3% 42.8%
Table- 1: Deals with Socio-demographic Sometimes Agree 40.5% 35.5% 30.0%
Totally Agree 11.5% 23.2% 27.2%
Characteristics of Sample
Groups Stereotyping
Totally Disagree 33.75% 29.4% 21.0%
Psychiatry Psychology PSW Sometimes Agree 38.75% 33.2% 40.0%
Variable Totally Agree 27.5% 37.4% 39.0%
Mean ± SD
Restrictiveness
N (%)
Totally Disagree 75.0% 61.5% 51.0%
Age 31.15 ± 4.12 25.68 ± 3.22 27.44 ± 3.67 Sometimes Agree 18.75% 22.4% 24.0%
Totally Agree 6.25% 16.1% 25.0%
Sex Male 15 (75%) 37 (27%) 7 (28%)
Benevolence
Female 5 (25%) 98 (73%) 18 (72%)
Totally Disagree 17.5% 22.3% 23.5%
Education Up to PG 18 (90%) 130 (96%) 25 (100%) Sometimes Agree 9.4% 24.2% 24.5%
Totally Agree 73.1% 53.5% 52.0%
Above PG 2 (10%) 5 (4%)
Pessimistic
Previous Yes 10 (50%) 48 (36%) 10 (40%) Prediction
Exposure No 10 (50%) 87 (64%) 15 (60%) 46.25% 28.7% 33.0%
Totally Disagree
15.0% 35.6% 26.0%
Sometimes Agree
38.75% 35.7% 41.0%
Table-1 shows the socio-demographic Totally Agree
GHWDLOV RI WKH UHVSRQGHQWV $ VLJQL¿FDQW JURXS Stigmatization
difference was found in the age where the Totally Disagree 92.5% 61.1% 63.0%
mean age of the psychiatry group was 31.15 in Sometimes Agree 3.75% 23.8% 16.0%
Totally Agree 3.75% 15.1% 21.0%
comparison to the clinical psychology (25.68)
and PSW (27.44) groups. 75% of the psychiatry Table-2 shows the group difference in
group was constituted of male population which terms of attitude towards mental illness. In the
was in contrary to the psychology and PSW separatism domain majority of the population
groups where majority of the respondents (73% from all the three groups (48%, 41.3% & 42.8%
and 72% respectively) were female. In terms of respectively) said that they totally disagree with
education similar kind of a representation was the statements. Which indicates that majority of
found for all the three groups where majority respondent were of the opinion that mentally
of population were educated up to PG i.e. 90%, ill patients should not be separated or treated
96% and 100% respectively. Talking about the differently from the other population. Results of
previous exposure in mental health 50% of the study indicated about the changing mind set
the psychiatry group had a previous exposure of the community.
where as 36% of the clinical psychology group Stereotyping domain came out with
and 40% of the PSW group said that they had a different type of responses as 33.75% of the
previous exposure. One of the possible reasons psychiatry group said that they totally disagree
could be the nature of the study curriculum. In where as 38.75% said that they sometimes agree.
other words during graduation in medicine they On the other hand 37.4% of the psychology
had a paper on psychiatry, as part of their study group and 39% of the PSW group said that they
curriculum where as it is not mandatory for rest totally agree with the statements which shows
of the two groups. that because of the exposure the psychiatry

57
 Sujit Kumar Mishra / Attitude towards Mental Illness among Students Appeared in the...
group disagreed about the notion the patients training might had contributed in this change.
suffering from mental illnesses would not remain
DISCUSSION
or behave dangerously always whereas the other
two groups responded the opposite way. 2YHUWKH\HDUVLWKDVEHHQD¿HOGRIFRQFHUQ
for many researchers to study the attitude of
In the restrictiveness domain most of the people belonging to various strata and category
respondents from all the three groups (75%, towards mental illness. Many studies that are
61.5% & 51% respectively) said that they totally DOUHDG\ EHHQ GRQH LQ WKH VDPH ¿HOG VXJJHVWHG
disagree with the statements that one should that variables such as age, sex, education etc.
not interact with the mentally ill person. The
KDYH GH¿QLWH LQÀXHQFH RQ WKH DWWLWXGH WRZDUGV
knowledge and concern of all the three groups
mental illness. In the present study, therefore, a
toward the mentally ill person was favourable.
YDULDEOHNQRZQDVSUHYLRXVH[SRVXUHLQWKH¿HOG
Similar kind of response were given by all
KDVEHHQLQFOXGHGLQRUGHUWR¿QGRXWWKHDWWLWXGH
the three groups for the benevolence domain
of various students who have some amount of
where 73.1% of the psychiatry group, 53.5% of
H[SRVXUHLQWKH¿HOGGLUHFWO\RULQGLUHFWO\DQG
the psychology group and 52.0% of the PSW
who have shown their interest to pursue their
said that they totally agree with the statements.
KLJKHUGHJUHHLQWKH¿HOGRIPHQWDOKHDOWK
7KLVDJDLQFRQ¿UPWKHLUXQGHUVWDQGLQJWRZDUGV
mentally ill persons. In the present study respondents were
asked to agree or disagree with a series of
In the pessimistic prediction domain most attitudinal statements about mental illness.
of the psychiatric group (46.25%) said that they These statements covered a wide range of
totally disagree where as most of the psychology issues, including stigma, the likelihood of
group (35.7%) and PSW group (41.0%) said that becoming mentally ill, and the possibility of
they totally agree with the statements. Because cure and medical treatment for persons with
RI WKH VFLHQWL¿F NQRZOHGJH DQG H[SRVXUH WKH mental illness. The results shown that there
psychiatric group had an optimistic view towards was evidence of both positive and negative
the mentally ill person. On the other hand the attitudes toward people with mental illness by
other two group shown pessimistic view. Finally, the students, with some differences in attitudes
in the stigmatization domain maximum number between all the three categories of students. One
of respondents from all the three groups i.e. of the important reasons could be the level of
92.5%, 61.1% and 63.0% respectively, said that H[SRVXUHLQWRWKH¿HOG$VZHNQRZSV\FKLDWU\
they totally disagree with the statements. On the students have to undergo training in psychiatry
other hand where only 3.75% of the psychiatry as a part of their study curriculum where as it
group said they totally agree, 15.1% of the is not mandatory for the rest two categories.
psychology group and 21.0% of the PSW group Again on the basis of the result it can be said
said that they totally agree with the statements. that those who already have the exposure in the
This factor shown the over all knowledge of all ¿HOGWKH\UHVSRQGHGGLIIHUHQWO\WRWKHTXHVWLRQV
the three groups towards mental illness. They i.e. positively in comparison to those who do not
are in view that the mentally ill person must be have the exposure.
treated with dignity and respect like any other 7KH¿QGLQJVDUHFRPSDUDEOHZLWKSUHYLRXV
person. But at the same time the results of the study that education about, and experience
study favours that the psychiatry group again working with, mental illness may assist the
had better view in terms of not to stigmatize the development of more positive attitudes toward
mentally ill person in comparison to other two mental illness. Especially, in accordance with
groups. The initial exposure to mental illness previous studies with nurses in particular, (Tay
and mentally ill person during their graduation et al., 2004; Hugo, 2001).

58
 Sujit Kumar Mishra / Attitude towards Mental Illness among Students Appeared in the...
CONCLUSION
Mental illness is as old as the human
civilization and it has been gone through many
stages of change in order to have a better
XQGHUVWDQGLQJDERXWWKHSUREOHPDVZHOODVWR¿QG
out the best possible way to manage it. Despite
so many efforts we are still lagging far behind
to have a better understanding of the situation
by accepting it. In this so called modern society
SHRSOH ZKR GR QRW KDYH VXI¿FLHQW DPRXQW RI
NQRZOHGJHDQGH[SRVXUHWRWKH¿HOGGREHOLHYH
that mental illness is nothing but a curse, it is
incurable and believe in the age old concept of
‘once mad forever mad,. In the present study
also revealed similar kind of notion and attitude
of participants towards mental illness. Although
the entire participant had some amount of
H[SRVXUH LQWR WKH ¿HOG LQ VSLWH RI WKDW WKH\
responded differently which showed that mental
illness is still being stigmatized and is a taboo.
Implication:
%DVHG RQ WKH ¿QGLQJV RI WKH SUHVHQW
VWXG\LWFDQEHVDLGWKDWGXHWRODFNRIVFLHQWL¿F
NQRZOHGJHDQGH[SRVXUHLQWRWKH¿HOGRIPHQWDO
health people form a negative attitude towards
mental illness and mentally ill. Therefore, it is
high time when a proper study curriculum for
the understanding of the importance of mental
health should be introduced right from the early Pescosolido, B., Link, B. G., Phelan, J., Bresnahan, M.,
DJHRIVWXG\$WWKHKLJKVFKRROOHYHODVSHFL¿F
chapter on mental health should be included as a
part of general science.
x
Limitations:
Since the distribution of sample in all the
three groups was not equal, therefore, the
¿QGLQJVFDQ¶WEHJHQHUDOL]HG
x
Exposure variable may be extended further
x
Pre and post analysis may be carried out to
VHHWKHGLIIHUHQFHVLQWKH¿QGLQJV
x
Previous education
REFERENCES:
Corrigan, P. (2004). How stigma interferes with mental
health care. American Psychologist. 59, 614–625.
Green, D. E., McCormick, I. A., & Walkey, F. H., et al.
(1987). Community attitudes to mental illness in
New Zealand twenty-two years on. Social Science
Medicine. 24, 417–422.
Holmes, P., & River, L. P. (1998). Individual strategies
for coping with the stigma of severe mental illness.
Cognitive and Behavioral Practice. 5, 231–239.
Hugo, M. (2001). Mental health professionals’ attitudes
toward people who have experienced a mental
health disorder. Journal of Psychiatric and Mental
Health Nursing. 8 (5), 419-425.
Huxley, P. (1993) Location and stigma: a survey
of community attitudes to mental illness:
enlightenment and stigma. Journal of Mental
Health UK. 2, 73–80.
Hyler, S. E., Gabbard, G. O., & Schneider, I. (1991)
Homicidal maniacs and narcissistic parasites:
stigmatisation of the mentally ill persons in
movies. Hospital and Community Psychiatry. 42,
1044 -1048.
Kaminski, P., & Harty, C. (1999) From stigma to strategy.
Nursing Standard. 13, 36-40.
Link, B. G., Struening, E. L., & Rahav, M. (1997) On
stigma and its consequences: evidence from a
longitudinal study of men with dual diagnoses
of mental illness and substance abuse. Journal of
Health and Social Behaviour. 38, 177–190.
& Stueve, A. (1999). Public conceptions of mental
illness: Labels, causes, dangerousness, and social
distance. American Journal of Public Health, 89,
1328–1333.
Phelan, J. C., Link, B. G., Stueve, A., & Pescosolido, B.
A. (2000). Public conceptions of mental illness in
1950 and 1996: What is mental illness and is it to
be feared? Journal of Health and Social Behavior.
41, 188–207.
Tay Sim-Eng, C., Pariyasami, S.D.O., Ravindran, K.,
Ali, M.I.A., & Rowsudeen, M.T. (2004) Nurses’
attitudes toward people with mental illnesses
in a psychiatric hospital in Singapore. Journal
of Psychosocial Nursing and Mental Health
Services. 42 (10), 40-47.
59
Indian Journal of Clinical Psychology Copyright, 2013 Indian Association of
2013, Vol. 40, No. 1, 60-62 Clinical Psychologists (ISSN 0303-2582)
Research Article
Association of Alcoholism with Personality and HIV-
A Hospital Based Study
Rupesh Choudhury1 and B.P. Mishra2

ABASTRACT
People with alcohol use disorders are more likely, than the general population, to contact HIV.
A history of heavy alcohol use has been correlated with the life term tendency towards high risk
sexual behaviours, including multiple sex partners, unprotected intercourse and the exchange
of sex for money and drugs. Present study aimed tRVHHWKHSHUVRQDOLW\SUR¿OHRIWKHDOFRKROLF
and its association with high risk sexual behaviours by using 16 PF questionnaire. The study
consists of 50 diagnosed cases of alcohol dependence syndrome, according to DSM-IV who
were assessed for sexual behaviour and personality. The Patients were also assessed once on
their mini mental status examination and their score was more than 25. Result suggests that the
RYHUDOOSHUVRQDOLW\SUR¿OHRIDOFRKROLFVUHÀHFWVORZIUXVWUDWLRQWROHUDQFHH[SHGLHQWVIHHOIHZ
obligations, aggressive with suspicious traits. They have intrusive thoughts and impulses. These
people have impulsive tension for which they are not able to locate the reason. The alcoholic
SDWLHQWVDUHPRUHDSSUHKHQVLYHUHJDUGLQJWKHLUVH[XDOHI¿FDF\DQGIHDURIEHFRPLQJLPSRWHQW
7KLVOHDGVWKHPWRJRIRUPRUHXQH[SORUHGVH[XDODFWWRFKHFNDQGUHFKHFNWKHLUVH[XDOHI¿FDF\
These personalities are more prone to impulsive sexual indulgence which may be unprotected or
VRPHWLPHVXQQDWXUDO+RPRVH[XDOLW\OHDGLQJWRZDUGV67'7RFRQFOXGHWKH¿QGLQJVLWLVFOHDU
that Alcoholic patients are more prone to HIV infections due to their personality and risky sexual
EHKDYLRXU7KH¿QGLQJVFDQEHZHOOXWLOL]HGIRUVSUHDGLQJNQRZOHGJHDQGDZDUHQHVVRIRQH¶V
own temperament and its negative impact on their health.
.H\ZRUGVAlcoholism, Personality, HIV.

INTRODUCTION as well as southern where prevalence of alcohol

Globally the epidemic of alcohol abuse and
HIV/AIDS are increasingly singled out as a major
area of concern for adolescent health. Alcohol use
and drunken behaviour is neither acknowledged
nor well documented, as contributing factors,
to the HIV/AIDS epidemic. This situation is
JUDGXDOO\ FKDQJLQJ 5HVHDUFKHUV KDYH FRQ¿UPHG
the connection between alcohol consumption and
+,9 IURP D VFLHQWL¿F SHUVSHFWLYH 3UHYDOHQFH
of alcohol use in India is generally regarded
as traditional “dry” or “abstaining” culture.
Prevalence of alcohol consumption ranged from a
low of 7% in the western state of Gujarat to 75% in
Northeastern state of Arunachal Pradesh.
India has the fourth largest population
suffering from AIDS. In 2007, India’s AIDS
prevalence rate stood at 0.30%- 89th highest in the
world. The spread of HIV in India is primarily
restricted to North eastern regions of the country
consumption is very high. People with alcohol
use disorders are more likely, than the general
population, to contact HIV (Petry, 1999). A history
of heavy alcohol use has been correlated with the life
term tendency towards high risk sexual behaviours,
including multiple sex partners, unprotected
intercourse and the exchange of sex for money and
drugs (Windle, 1997; Avins, 1994; Malow, 2001).
Studies consistently demonstrated that
people who strongly believe that alcohol enhances
sexual arousal and performance are more likely
to practice risky sexual encounter after drinking
(Cooper, 2002; Derman, 1998; George, 2000).
Some people reported deliberately using alcohol
during sexual encounters to provide an excuse
for socially unacceptable behaviour or to reduce
their conscious awareness of risk. According to
Mckirnan and colleagues (2001), this practice may
be especially common among men who have sex

1. Assistant Professor, Psychiatry 2. Professor, Clinical Pshychology, Dept. of Psychiatry, DMC&H, Ludhiyana, Punjab, India
Corresponding Author E-mail : bholesh@rediffmail.com

60
Rupesh Choudhury / Association of Alcoholism with Personality and HIV- A Hospital Based Study
ZLWKPHQ7KH¿QGLQJVDUHDOVRVXSSRUWHGE\6WDOO 7DEOH3)3UR¿OHRIWKH3DWLHQWV
(1986) and Maslow (1999). FAC-
MEAN SD PERSONALITY CHARACTERISTICS
TORS
Aim of the Study: A 5.16 1.517 Extroversion And Introversion Tendencies
7RVHHWKHSHUVRQDOLW\SUR¿OHRIWKHDOFRKROLF B 3.36 1.651 Intelligence Utility
patients and high risk sexual behaviour and its C 3.38 1.259 Emotional Strength And Reactivity
association with various personality traits. E 6.6 1.049 Submissive Versus Assertive Traits
F 6.12 1.612 Surgency Versus Desergency Traits
MATERIAL AND METHOD
The study was carried out on indoor patients G 3.30 1.741 Superego Strengths
of department of psychiatry, Dayanand Medical H 4.68 1.571 Shy Versus Spontaneous Traits
College and Hospital, Ludhiana, Punjab, India. The I 5.16 1.517 Independent Versus Dependent Traits
sample consist of 50 diagnosed cases of alcohol L 8.52 1.240 Trusting Versus Suspicious Traits
dependence syndrome followed DSM IV criteria. M 7.92 0.752 Practical Versus Imaginative Traits
Sexual behaviour and personality assessment of N 5.30 1.528 Sentimental Versus Shrewd Traits
all the 50 diagnosed cases of alcohol dependence O 7.62 1.550 KJł@AJ?A3ANOQO4KNNUEJC1N=EPO
syndrome, was done. The patients were assessed Q1 5.54 1.740 Conservative Versus Experimenting Traits
once on mini mental status examination where Q2 6.50 1.249 $NKQL!ALAJ@=J?A3ANOQO0AHB0QBł?EAJ?U
score was more than 25. Before carrying out 2J@AO?ELHEJA@0AHB KJł@AJ?A3ANOQO
Q3 4.12 1.674
evaluation, the morning medication was withheld. Socially Precise Traits
Finally, 16 PF questionnaire for personality Q4 8.84 1.376 Relaxed Versus High Ergic Tension
evaluation was administered. 7DEOHUHÀHFWVWKHSHUVRQDOLW\SUR¿OHRIWKH
The Sixteen Personality Factor Questionnaire (16 PF) : patients on 16 PF. These patients are found to be
always prone to decide impulsively rather than using
16 PF is a multiple-choice personality
their intellectual ability or reasoning (low score on
questionnaire (Raymond B. Cattell, 1949). The test
IDFWRU%RI3)6LJQL¿FDQWO\ORZPHDQVFRUHRQ
provides scores on 16 primary personality scales
IDFWRU&LHUHÀHFWVWKHLUWHQGHQF\WR
and 5 global personality scales, all of which are
get upset and frustrated on small things. They have
bi-polar (both ends of each scale have a distinct,
low frustrations tolerance. This type of emotional
PHDQLQJIXOGH¿QLWLRQ7KHWHVWDOVRLQFOXGHVWKUHH
status leads to premature ejaculation and erectile
validity scales: a bi-polar Impression Management
dysfunction since patient easily gets distracted to
(IM) scale, an Acquiescence (ACQ) scale, and an
RWKHU WKLQJV 6LJQL¿FDQW ORZ VFRUH RQ IDFWRU *
Infrequency (INF) scale. The reasoning ability
(Factor B) items appear at the end of the test
booklet with separate instructions, because they are
the only items that have right and wrong answers.
RESULTS
The demographic characteristics of the may harm them which in turn may lead to over
sample was shown in Table -1
UHÀHFWVWKHLUWHQGHQF\WRLJQRUHWKHLUVRFLDO
boundaries and expected activity in different social
VLWXDWLRQV7KHUHLVVLJQL¿FDQWHOHYDWLRQRQIDFWRU
L (8.52) reveals their tendency to disbelieve others
around them and strong suspiciousness that other’s
arousal and anxiety which are very well known
FDXVH RI VH[XDO G\VIXQFWLRQV 6LJQL¿FDQWO\ KLJK
7DEOH2EVHUYDWLRQV6RFLR'HPRJUDSKLF3UR¿OH1  VFRUHRQIDFWRU0UHÀHFWVWKHWHQGHQF\RI
EDUCATION UP TO MATRIC TO POST imagination, lost in fantasy and always wrapped up
AGE (YEARS) MATRIC GRADUATION GRADUATION in inner urgencies. These traits again lead to high
20-30 05 10 05 arousal VWDWHZKLFKZLOODIIHFWWKHVH[XDOHI¿FDF\
30-40 08 07 05 6LJQL¿FDQWO\ KLJK VFRUH RQ IDFWRU  UHÀHFWV
40 ABOVE 03 04 03 apprehensive tendencies. These type of people are
$ERYHWDEOHUHÀHFWVWKDWPDMRULW\RISDWLHQWV always worrying for small things and very prone
were from the age group of 20-40 years (80%), to depressive cognition which are again a known
and majority of them were educated up to the factor for sexual inadequacy. Very high score on
graduation level (42%). Only 26% sample were IDFWRU4UHÀHFWVKLJKLPSXOVLYLW\DQGHUJLF
educated up to post graduation level. tension. This parameter on 16 PF is found to be high

61
Rupesh Choudhury / Association of Alcoholism with Personality and HIV- A Hospital Based Study
ZKHQIUHHÀRDWLQJDQ[LHW\LVSUHVHQWDQGWKHSHUVRQ
is tense and frustrated without any obvious reason.
DISCUSSION
The term impotency is very fearful and
discomforting for a male in our society due to
which they feel strong inner pressure to check and
UHFKHFNWKHLUVH[XDOHI¿FDF\WRFRQ¿UPWKDWWKH\
are not impotent. Sometimes these tensions and
frustration make alcoholics so impatient due to
which they go for unnatural sexual encounter which
in turn increase high risk for developing sexual
following addiction treatment. Drug and Alcohol
Dependence. 44 (1), 47–55.
Cattell, R.B. (1946). The Description and Measurement of
Personality. New York: World Book.
Cook, R.L., Sereika, S.M., & Hunt, S.C. (2001). Problem drinking and
medication adherence among patients with HIV infection.
Journal of General Internal Medicine. 16 (2), 83–88.
Cooper, M.L. (2002). Alcohol use and risky sexual behavior among
college students and youth: Evaluating the evidence.
Journal of Studies on Alcohol. (Suppl, 14), 101–117.
Dermen, K.H., Cooper, M.L., & Agocha, V.B. (1998). Sex-related
alcohol expectancies as moderators of the relationship
between alcohol use and risky sex in adolescents.
Journal of Studies on Alcohol. 59 (1), 71–77.
WUDQVPLWWHG GLVHDVH 7KHVH ¿QGLQJV DUH FRQVLVWHQW
with the observation that alcohol abuse occurs
more frequently among people whose life style or
personality predisposes them to high risk sexual
behaviour (Avins, 1994 & 1997; Justus, 2000;
Perry, 1998; Mac Donald, et al., 2001). As these
patients are impulsive, ignore social boundaries and
'HUPHQ .+  &RRSHU 0/  ,QKLELWLRQ FRQÀLFW
and alcohol expectancy as moderators of alcohol’s
relationship to condom use. Experimental and Clinical
Psychopharmacology. 8 (2), 198–206.
George, W.H.; Stoner, S.A., & Norris, J. (2000). Alcohol
H[SHFWDQFLHV DQG VH[XDOLW\ $ VHOIIXO¿OOLQJ SURSKHF\
analysis of dyadic perceptions and behaviour. Journal of
Studies on Alcohol. 61(1). 168–176.
expected social activities, they consume alcohol
to provide an excuse for socially unacceptable
behaviour or to reduce their conscious awareness of
ULVNZKLFKLVFRQVLVWHQWZLWKWKH¿QGLQJVRIRWKHU
researchers (Dermen, & Cooper, 1998, 2000).
CONCLUSIONS
Alcohol is commonly used as a disinhibitor,
a sex facilitator, extra power for sex, a symbol
of masculinity and a means of relaxation.
Masculinity is often linked to the ability to have
multiple partners, imbibe alcohol and engage in
promiscuous behaviour, thus resulting in risky
sexual encounters and sexual victimization
Alcoholic patients are more prone to HIV and
other STD infections due to their personality
FKDUDFWHULVWLFV 7KH ¿QGLQJV FDQ EH ZHOO XWLOL]HG
for spreading knowledge and awareness of one’s
own temperament and its negative impact on
their health as well as to prepare effective long
term management plan for alcoholism and to take
preventive measures in HIV awareness campaign.
As the association between de-addiction services and
HIV screening, testing and counselling is nascent,
the HIV prevention programs should be included in
the de-addiction clinics and conversely addressing
alcohol use in AIDS prevention programs.
References
Avins, A.L., Woods, W.J., & Lindan, C.P. (1994). HIV infection
and risk behaviours among heterosexuals in alcohol
treatment programs. JAMA, 271 (7), 515–518.
Avins, A.L., Lindan, C.P., & Woods, W.J. (1997). Changes in
HIV-related behaviours among heterosexual alcoholics
62
-XVWXV$1)LQQ35 6WHLQPHW]-(7KHLQÀXHQFH
of traits of disinhibition on the association between
alcohol use and risky sexual behavior. Alcoholism:
Clinical and Experimental Research. 24 (7), 1028–1035.
MacDonald, T.K., MacDonald, G., Zanna, M.P., & Fong, G.T.
(2000). Alcohol, sexual arousal, and intentions to use
condoms in young men: Applying alcohol myopia theory to
risky sexual behaviour. Health Psychology. 19 (3), 290–298.
McKirnan, D.J., Vanable, P.A., Ostrow, D.G., & Hope, B.
(2001). Expectancies of sexual “escape” and sexual risk
among drug and alcohol-involved gay and bisexual men.
Journal of Substance Abuse. 13 (1–2),137–154.
Malow, R.M., Dévieux, J.G., & Jennings, T. (2001). Substance-
abusing adolescents at varying levels of HIV risk:
Psychosocial characteristics, drug use, and sexual
behaviour. Journal of Substance Abuse. 13, 103–117.
Maslow, C.B., Friedman, S.R., & Perlis, T.E. (2002). Changes in
HIV seroprevalence and related behaviours among male
injection drug users who do and do not have sex with
men: New York City, 1990–1999. American Journal of
Public Health. 92(3), 382–384.
Perry, M.J., Solomon, L.J., & Winett, R.A., (1994). High risk
sexual behaviour and alcohol consumption among bar-
going gay men. AIDS. 8 (9),1321–1324.
Petry, N.M. (1999) Alcohol use in HIV patients: What we don’t
know may hurt us. International Journal of STD and
AIDS. 10 (9), 561–570.
Stall, R., McKusick, L., & Wiley, J. (1986). Alcohol and drug
use during sexual activity and compliance with safe sex
guidelines for AIDS: The AIDS Behavioral Research
Project. Health Education Quarterly. 13 (4), 359–371.
Stall, R., Paul, J.P., & Greenwood, G. (2001). Alcohol use,
drug use and alcohol-related problems among men who
have sex with men: The Urban Men’s Health Study.
Addiction. 96 (11), 1589–1601.
Wagner, J.H., Justice, A.C., & Chesney, M. (2001). Patient- and
provider-reported adherence: Toward a clinically useful
approach to measuring antiretroviral adherence. Journal
of Clinical Epidemiology. 54 (12 Suppl. 1), S91–S98.
Indian Journal of Clinical Psychology
2013, Vol. 40, No. 1,63-64
Guidelines IRU
Organizing Conference of Indian Association of Clinical Psychologists
Manju Mehta1, Gauri Shanker2 and Masroor Jahan3
Publication of Indian Association of Clinical
Psychologists (2013)
IACP Conference is organized annually in the
month of January/ February. The proposal to organize
the conference is to be obtained by Executive Council.
GENERAL GUIDELINES
Time, Duration and Venue:
The conference may be organized in the month of
January / February for 3 days. However, pre- and post-
conference workshops/Seminars may be conducted.
Announcements:
1st announcement of the conference should
FRPH E\ $SULO  0D\ 6XEVHTXHQW DQG ¿QDO
announcement should come no later than November/
end of December.
Registration Fee:
Registration fee should be separate for members
of IACP, non members, students and accompanying
persons. Non members are required to pay 10 – 20%
more than the registration fee for IACP members,
whereas students are required to pay 25 – 50% less
than IACP members. Accompanying persons are
required to pay 20 – 40% lesser. They are allowed
to attend the conference but are not entitled to the
conference kits. If possible senior citizens should be
exempted from registration fees or should be given
some discount in the registration fee.
Registration fee shall be waived off for core
Executive members namely President, President elect,
Past President, General Secretary, Editor and Treasurer.
Proposals for symposium/workshop:
Deadline of date, GUDIW DQG ¿QDO WH[W
submission must be clearly mentioned in the 1st
announcement. Theme/ Title of the symposium/
workshop must be clearly stated and submitted no
later than October.
Paper/ Poster Presentations:
Deadlines dates for abstract submission must
be given in the 1st announcement. Paper/ Poster
presentations are essential and must be treated so by
the organizers, with special emphasis on effective
management of time. Chairpersons must be informed
for the time and duration of the sessions well in
advance. Each participant must be allowed at least
1. Professor of Clinical Psychology, Dept. of Psychiatry, AIIIMS, New Delhi and President, IACP 2. Assistant Prof., National Drug Dependance
Treatment Centre, AIIMS, Ghaziabad 3. Additional Professor, of Clinical Psychology, RINPAS, Kanke, Ranchi and Hon' Gen. Secretary, IACP
63
Copyright, 2013 Indian Association of
Clinical Psychologists (ISSN 0303-2582)
ten minutes to present, inclusive of two minutes
for discussion; and only the index person having
registered in the conference is to be allowed to
present the paper/ poster. No participant is allowed
to present more than one paper/ poster. Full papers
may be asked for only in case of the conference
proceedings being published.
Transparent criteria for oral and poster presentations:
Different criteria are to be developed by the
organizers for oral and poster presentations, and must
EHPHQWLRQHGFOHDUO\LQWKH¿QDODQQRXQFHPHQW&DVH
studies are to be placed under posters or should be put
in different category.
Awards for best paper in each session:
7KH VFLHQWL¿F FRPPLWWHH RI WKH FRQIHUHQFH
is required to allot papers to different categories
based on the abstracts received and their themes. As
assessed by the Chairperson of the session, based on
the presentation style, content, topic, methodology and
results, one paper would be awarded Best Paper for
each session. If more than 100 abstracts are received,
organizers may appoint Judges to select 2 best papers
SUHVHQWHG LQ WKH FRQIHUHQFH $ FHUWL¿FDWH LV WR EH
awarded for Best Paper during the valedictory session.
Chairpersons:
&KDLUSHUVRQVRIWKHVFLHQWL¿FSURJUDPDUHWREH
decided by the organizing committee. Chairpersons
and Co-Chairpersons are generally experts in the area
that is the general theme of the session and have done
substantial research in the same.
Accommodation and Transport:
Adequate arrangements must be made to
accommodate participants who have requested for
boarding and lodging; or it should be ensured that they
can avail such facilities easily. Transport facilities to
and from the accommodation; if possible, must be
arranged by the organizing committee. Arranging
transport to and from airport/ railway station etc. is at
the discretion of the organizing committee.
Hospitality:
Lunch and Tea must be provided to the
participants. One Banquet to be arranged. The
charges are included in the registration fee.
 Manju Mehta / Organizing Conference of Indian Association of Clinical Psychologists
+RVSLWDOLW\RI2I¿FH%HDUHUVRI,$&3
,$&3RI¿FHEHDUHUV3UHVLGHQW3UHVLGHQW(OHFW
Immediate Past President, Editor, Treasurer and
General Secretary) must be provided free hospitality,
including accommodation and food during the
FRQIHUHQFH$OORWKHU(&PHPEHUVEDUULQJWKHRI¿FH
bearers, are required to pay registration fees.
FUNCTIONS
Inauguration:
The chief guest and other guests for the
inaugural function are to be decided by the organizing
committee. However, the IACP President, General
Secretary, Chairperson and Secretary of the Organizing
Committee must also be seated on the dais.
Seating in the Inaugural function:
President and General Secretary will sit on the
dais, along with Organizing chairperson, organizing
secretary and chief guest of the conference.
IACP Awards:
Currently, 6 awards; namely H N Murthy,
C S Kang, Psycho- Oration, IACP Child and
Adolescent Mental Health Award previously known
as Asha Nigam Award, S C Gupta Best Paper, Young
Scientist Award (age limit below 35 years of age);
and Forensic Psychology Award are awarded each
year to those distinguished members (Fellow and
PLM only) who have done commendable work in
the feild respective areas of clinical psychology. The
award amount will be Rs. 1500/- for the former 4
awards and Rs 1000/- for the S C Gupta award. The
DZDUGFRQVLVWVRIDFLWDWLRQFHUWL¿FDWHDPHPHQWR
The expenditure incurred is to be borne by IACP,
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the treasurer IACP in the subsequent year. Date,
time, venue and other guidelines for presentation of
oration in the conference will be communicated by
organizing committee to the awardees in advance.
Chairpersons for IACP Award Sessions:
All the IACP award sessions will be chaired by
WKHRI¿FHEHDUHUVRQO\
C S Kang Oration President
H N Murthy Award President elect
Psycho Oration Immediate Past President
IACP Child and Adolescent Editor
Mental Health Award
S C Gupta Best Paper Award General Secretary
Forensic Psychology Award Awarded in the valedictory
In case of non availability of a particular
chairperson, President IACP may invite any Senior
64
)HOORZ0HPEHUWR&KDLUWKHDZDUG1RRI¿FHEHDUHU
may chair more than one session.
General Body Meeting:
Notice of General Body should be circulated
one month in advance, in which date, time, venue
and agenda should be mentioned. In the GB Meeting,
President, Secretary and Treasurer would be on
the dais. The quorum of GB Meeting is 1/12th of
the total number of PLM and Fellow Members of
IACP. Effort must be made to ensure that maximum
number of PLM and Fellow Members can attend
it. If the quorum is not complete, then the meeting
can be adjourned, and can be started after 5 minutes.
Following reports would be read in the GB Meeting:
Condolence, if required.
General Secretary would present minutes of
the previous GB Meeting.
Report by the Treasurer (Audited Report)
Report by the Editor
Report by the Chapters
Report by subcommittees
Important issues pertaining to profession
Announcement about next conference
Any other matter with the permission of
President.
6XI¿FLHQW WLPH RI DERXW  ±  KRXUV LV WR EH
allotted by the organizers for the General Body
Meeting. The expenses towards the GB meeting are
to be borne by the organizers, however, expenses
for printing/ Xeroxing of different reports (such as
Auditor’s Report) will be borne by Treasurer of IACP.
The responsibility of conducting the GB Meeting
smoothly lies with the organizing committee.
The GB Meeting would end by handing over
the charge to the next team, every second year (end
of the term of EC).
Valedictory: The guests for this function are to
be decided by the organizing committee. President,
General Secretary, and Treasurer of IACP should also
sit on the dais along with the organizing committee
members. The function would proceed as follows:
The function would begin with welcome and
remarks from chief guest on the dais.
The report of the conference would be
presented by the organizing secretary.
S C Gupta Award, Forensic Psychology Award
and Best Paper Award would be awarded.
Feedback from the participants.
The function would end with vote of thanks.
Indian Journal of Clinical Psychology Copyright, 2013 Indian Association of
2013, Vol. 40, No. 1, 65-88 Clinical Psychologists (ISSN 0303-2582)
Indian Association of Clinical Psychologists
Practice Guidelines : Learning Disability
Annie John1, Akila Sadasivan2, Bhasi Sukumaran3, Poornima Bhola4,
Neena J. David5 and L. S. S. Manickam6

Note from the authors perception, and social interaction may exist with
Due to the burgeoning awareness of students learning disabilities but do not, by themselves,
DIIHFWHG E\ 6SHFL¿F /HDUQLQJ 'LVDELOLW\ &OLQLFDO constitute a learning disability.
Psychologists in India are coming across this Although learning disabilities may occur
condition with increasing frequency. These guidelines concomitantly with other disabilities (e.g., sensory
have been prepared to enable the Indian Clinical impairment, mental retardation, serious emotional
Psychologists to provide high quality and consistent GLVWXUEDQFHRUZLWKH[WULQVLFLQÀXHQFHVVXFKDV
psychological service in this emerging area of FXOWXUDOGLIIHUHQFHVLQVXI¿FLHQWRULQDSSURSULDWH
SUDFWLFH7KHWHUP6SHFL¿F/HDUQLQJ'LVDELOLW\VKDOO instruction), they are not the result of those
be referred to as SLD and the Clinical Psychologist FRQGLWLRQVRULQÀXHQFHV1-&/'
as Clinical Psychologist. The authors have attempted
SLD refers to a heterogeneous group of disorders
to use current research and their own experience
ZKHUHVLJQL¿FDQWGLI¿FXOWLHVLQWKHDFTXLVLWLRQDQGXVH
while compiling this document. The main aim of
of listening, speaking, reading, writing, reasoning, or
these guidelines is to aid the Clinical Psychologist mathematical skills are present.
in the process of assessment and intervention of
children or adolescents with SLD. It is also, however, These disorders are intrinsic to the individual,
understood that the role of the psychologist is not presumed to be due to central nervous system
FRQ¿QHGWRDVVHVVPHQWDQGWKHLQWHUYHQWLRQSURFHVV dysfunction, and may occur across the life span.
only. Dissemination of information about SLD in Problems in self-regulatory behaviours, social
the community – parents, teachers and to other care perception, and social interaction may exist with
givers, is essential. Teachers and other mainstream learning disabilities but do not, by themselves,
educators should be introduced to the prevalence of constitute a learning disability. (NJCLD, 1990)
SLD, the common manifestations of the disability 7KH JURZLQJ DZDUHQHVV RI 6SHFL¿F /HDUQLQJ
and its impact on the student. Disabilities in India stresses the need for standardized
assessment practices and educational remediation
INTRODUCTION methods. A review of the literature on research done
To facilitate a clear understanding of the term in the area of Learning Disabilities in the Indian
6SHFL¿F /HDUQLQJ 'LVDELOLWLHV WKH DXWKRUV KDYH context reveals that while there has been a smattering
GHFLGHG WR XVH WKH GH¿QLWLRQ SXW IRUZDUG E\ WKH of studies in the different aspects of SLD, there has
National Joint Committee on Learning Disabilities been no sustained, rigorous research done in any
(1998). VSHFL¿FDUHD
Learning Disabilities is a general term Epidemiological Data on the prevalence
that refers to a heterogeneous group of disorders of Learning Disabilities in India have been sparse
PDQLIHVWHG E\ VLJQL¿FDQW GLI¿FXOWLHV LQ WKH GXH WR WKH PDQ\ GLI¿FXOWLHV LQKHUHQW LQ WKH ,QGLDQ
acquisition and use of listening, speaking reading, situation. Suresh and Sebastian (2003) have noted
writing, reasoning, or mathematical skills. that the research on the prevalence of learning
These disorders are intrinsic to the disabilities in India is limited and there is certainly
individual, presumed to be due to central nervous no data that can be quoted about the Indian situation.
system dysfunction and occur across the life span. There have been no prospective longitudinal studies,
Problems in self-regulatory behaviours, social and there is little information on the prevalence of
1. Currently working in the European School Karlsruhe, Germany. Formerly Head, Learning Support, Mallya Aditi International
School, Bangalore. 2. Child Neuropsychologist, Director Child Mental Health Services, Institute of Social Initiative, Behaviour
&KDQJHDQG1HXURVFLHQFHV6,%&216'LUHFWRURI6$09,'+1HXURSV\FKRORJLFDOUHPHGLDWLRQFHQWUHIRUFKLOGUHQ&DQW1HZ
Zealand 3. Department of Clinical Psychology, Sri Ramachandra University, Porur, Chennai. 4. Assistant Professor of Clinical
Psychology, St. John’s Medical College Hospital, Bangalore – 560 034. 5. Head, Counseling Services, Mallya Aditi International
School, Bangalore. 6. Professor in Clinical Psychology, Dept. of Psychiatry, JSS University, Mysore.

65
 Annie John / Practice guidelines : Learning Disability

SLD with other psychiatric disorders like ADHD, in 5 areas – Verbal disability, oral attention disability,
among Indian children and adolescents. They have writing disability, mathematical computation
however, reported a ‘large incidence’ of learning disability and written attention disability. They
GLI¿FXOWLHV LQ UXUDO DUHDV LQ .HUDOD -RKQ 
found a distinct group of children with features of a
VSHFL¿F OHDUQLQJ GLVDELOLW\ DPRQJ WKRVH SUHVHQWLQJ
with scholastic backwardness in the Child Guidance
&OLQLF LQ 1,0+$16 0RVW VWXGLHV KDYH GLI¿FXOW\
in distinguishing between learning disability and
OHDUQLQJ GLI¿FXOW\ 7KH\ KDYH QRWHG WKDW WKH LVVXHV
VSHFL¿FWRWKH,QGLDQFRQWH[WWKDWDUHYDULRXV7KHVH
include bilingualism and multilingualism, classroom
and school contexts in rural areas, parental illiteracy,
medium of instruction and socio-economic factors
associated with environmental, cultural and economic
disadvantages.
,GHQWL¿FDWLRQ$VVHVVPHQWDQG'LDJQRVLVRI
Learning Disabilities in India:
Kapur, John, Rozario and Oommen (1991)
developed the NIMHANS Index for SLD – Level
1 for assessment of pre-academic skills for children
between 5 to 7 years – attention, visual and auditory
discrimination, visual and auditory memory, speech
and language, visuomotor and language, writing and
number skills. The Level II for Classes 1-7 assess
the areas of attention, reading, spelling, perceptuo-
motor, visuo-motor integration, memory and
arithmetic skills. This battery of tests is usually used
in conjunction with the Malin’s Intelligence Scale
for Children. Initial efforts at developing norms
(Hirisave & Shanti, 2002) have been made.
Sankaranarayana (2003) used reading
DVVHVVPHQW WHVWV OHWWHU LGHQWL¿FDWLRQ ZRUG
recognition, and reading tests) as well as tests used
with children in the Western literature such as
Rhyming, Torgeson Elision, Rapid Automatized
Name, Rapid Alternating Stimulus, Short-term
memory for Digits, Conservation, Handedness and
LGHQWL¿HGSHUFHQWRIVFKRROFKLOGUHQ\UV
as learning disabled in rural schools in Allahabad.
They found more boys than girls (B= 2.66; G= 1.71)
having a Learning Disability.
Assessment of Learning Disabilities should also
include screening and evaluation of other co-morbid
FRQGLWLRQV OLNH $WWHQWLRQ 'H¿FLW +\SHUDFWLYLW\
Disorders. Crawford (2007) highlighted the fact
that both SLD and ADHD existing co-morbidly are
under-recognised in India. Karande, et al. (2007)
UHSRUWHGSUR¿OHVRIFKLOGUHQGLDJQRVHGZLWK6/'
and /or ADHD. The average age at which the children
were diagnosed was 11.36 years (with a range from
7 to 17 years), while the average age at which the
FKLOGUHQ¶VV\PSWRPVKDG¿UVWEHHQQRWLFHGZDVRQO\
5.55 years (with a range from 4 to 6 years). The delay
EHWZHHQV\PSWRPV¿UVWEHLQJQRWLFHGDQGWKHFKLOG
being diagnosed with SLD and ADHD was nearly 6
years on the average.
Language and Learning Disabilities in India:
As educational facilities in most of rural India
are in the regional language there is a need to have
assessment tools in the different mother tongues or the
medium of instruction of the students. Prema (1998)
GHYHORSHGWKH5HDGLQJDFTXLVLWLRQ3UR¿OHLQ.DQQDGD
– a language based reading assessment battery.
Sharma (2000) explored the language skills
of 23 Hindi speaking children with LD (7-15
years). They were evaluated on the Hindi version
RI WKH /LQJXLVWLF 3UR¿OH7HVW .DUDQWK HW DO 
Sharma, 1995). Children with LD perfomed poorer
than children without LD and they found that syntax
and semantics were affected more than phonemics.
The same study was repeated with 21 Malayalam
VSHDNLQJ /' FKLOGUHQ DQG UHSRUWHG VLPLODU ¿QGLQJ
Vocabulary. They found that the best predictors and
phonological awareness. Rozario (2003) emphasized
WKHQHHGIRULQGLYLGXDOLVHGSUR¿OHV
Konanthambigi and Shetty (2008) used the
Behavior Checklist for Screening the Learning
Disabled and Swarup and Mehta (1991) – developed
a scale at the Special Education Cell of the SNDT
Women’s University – for teachers to identify
learning problems in children.
The Learning Disabilities Scale developed by
Yadav and Agarwal (2008) consists of 19 questions
66
*HRUJH $Q DGGLWLRQDO ¿QGLQJ ZDV WKDW WKH
gap between the chronological age and language age
of the children increased with age.
Balasubrahmanyam (2001) speculated that the
incidence of dyslexia would be less in India as those
literate in Indian scripts, received intensive phonic
training and that the Indian methods of writing
(orthographic) were transparent. Karanth (2002)
also suggested that the syllabic nature of most Indian
scripts along with the high degree of grapheme-
phoneme correspondence meant that a lower level
 Annie John / Practice guidelines : Learning Disability
of phonological awareness would be required for
learning to read. However, other characteristics of
,QGLDQODQJXDJHVFRXOGOHDGWRVLJQL¿FDQWGLI¿FXOWLHV
with reading at phrasal and sentence levels. The
implications from this research would be that
informed choices on medium of instruction and
method of teaching (e.g. phonic method) for learning
disabled children could be guided by a detailed
language assessment. Gupta (2008) analysed the
Lall, Hirisave, Kapur and Subbakrishan
(1997) examined perceived peer relations and social
FRPSHWHQFHLQFKLOGUHQZLWKVSHFL¿FGHYHORSPHQWDO
disorders of scholastic skills. A sample of twenty
children with disorders of scholastic skills aged,
seven to twelve years and twenty controls matched
on age, class and IQ were taken. The two groups
were assessed on (i) A semi-structured interview
schedule (ii) Malin’s Intelligence Scale for Indian
reading errors of Hindi-speaking dyslexic children
and found a greater number of graphemic errors.
Karanth (2008) observed that conversational
level of LD children could be adequate, though they
PD\ KDYH VSHFL¿F GHOD\V RU GH¿FLWV LQ ODQJXDJH
acquisition on formal language assessment.
Research with other Indian languages would
need to be integrated into research on prevalence
of LD in children with medium of instruction other
than English. However, it is clear that LD is found
in Indian children from both English speaking and
vernacular backgrounds.
Psychosocial Aspects of Learning Disabilities in India:
Mukerjee, Hirisave, Kapur and Subbakrishna
(1995) aimed at examining anxiety and self-esteem
LQFKLOGUHQZLWK6SHFL¿F'HYHORSPHQWDO'LVRUGUVRI
Scholastic Skills (SDDSS). A purposive sample of 40
children between the ages of 8-13 years, attending
English medium schools, with IQs above 80 was
WDNHQ 2I WKHVH  FKLOGUHQ IXO¿OOLQJ WKH ,&'
criteria for SDDSS, were taken from a Child and
Adolescent Mental Health Unit, and compared to 20
non-SDDSS children drawn from nearby schools.
Both groups were assessed on: (1) A semi-structured
interview schedule (2) Malin’s Intelligence Scale for
Indian Children (MISIC) (3) NIMHANS Index for
&KLOGUHQ0,6,&LLL1,0+$16,QGH[IRUVSHFL¿F
learning disabilities (iv) Perceived peer relations
questionnaire (v) Interpersonal competence scale –
Teacher version. Results revealed that children with
scholastic skill disorder perceived their relationship
with peers as cordial. However, teachers found
these children as poorer in social competence and
GLPHQVLRQVRIDFDGHPLFVSRSXODULW\DI¿OLDWLRQDQG
sportsmanship qualities.
Bhola, Hirisave, Kapur and Subbukrishnal
(2000) studies Self esteem and self perceptions
in children with learning disability in a purposive
sample of 40 children, 8-13 years, with IQs over
 7KH VDPSOH KDG  FKLOGUHQ ZLWK VSHFL¿F
developmental disorders of scholastic skills and
20 age and sex matched normal achievers. Two
JURXSV ZHUH DVVHVVHG RQ WKH &XOWXUHVSHFL¿F 6HOI
Esteem Inventory for Children. Self Perception of
Learning Disability Scale was administered to the
children with SDDSS. Results indicated that learning
GLVDEOHG FKLOGUHQ KDG VLJQL¿FDQWO\ ORZHU DFDGHPLF
social, parental and general self-esteem. The child’s
SHUFHSWLRQ RI OHDUQLQJ GLVDELOLW\ KDG VLJQL¿FDQW
positive associations with academic, social, general
DQG WRWDO VHOIHVWHHP OHYHOV EXW QRW VLJQL¿FDQWO\
associated with parental self-esteem. Hirisave
6SHFL¿F/HDUQLQJ'LVDELOLWLHV6WDWH7UDLW$Q[LHW\
Inventory for Children and (5) Culture-Free Self-
Esteem Inventory for Children. The obtained data
was analysed using descriptive statistics, parametric
and non-parametric tests. Findings revealed a
VLJQL¿FDQW GLIIHUHQFH LQ WKH VHOIHVWHHP RI FKLOGUHQ
with and without SDDSS. Particularly, low parental,
academic and general self-esteem were seen in
SDDSS children (p < 0.01). The SDDSS children
and Shanti (2002) studies behavioral problems in
FKLOGUHQ ZLWK VFKRODVWLF VNLOO GLI¿FXOWLHV$ VDPSOH
of children (n=20) aged 5 to 8 years with scholastic
GLI¿FXOWLHV ZDV FRPSDUHG ZLWK WKRVH ZKR GLG QRW
KDYHGLI¿FXOWLHV5HVXOWVUHYHDOHGWKHJUHDWHUQXPEHU
of externalizing, internalizing and learning problems
LQ FKLOGUHQ ZLWK VFKRODVWLF GLI¿FXOWLHV 7KH QHHG
for management of behavioral problems along with
UHPHGLDWLRQRIVFKRODVWLFGLI¿FXOWLHVZDVKLJKOLJKWHG
DOVRKDGVLJQL¿FDQWO\KLJKHUVWDWHDQ[LHW\S
EXWGLGQRWGLIIHUVLJQL¿FDQWO\RQWUDLWDQ[LHW\VFRUHV
Moreover, parental self-esteem was found to be
VLJQL¿FDQWO\UHODWHGWRVWDWHDQGWKHLULPSRUWDQFHLQ
planning intervention for the SDDSS children, both
in the clinic and school settings.
67
Kohli, Malhotra, Khehra and Mohanty (2007)
studied 46 children using the NIMHANS Index of
6SHFL¿F /HDUQLQJ 'LVDELOLWLHV LQ WKH DJH UDQJH RI
7-14 years with SLD. They were primarily boys
who attended the outpatient service of the Child
and Adolescent Psychiatric Clinic at PGIMER,
 Annie John / Practice guidelines : Learning Disability
Chandigarh. The children reported various clinical were administered. The results indicated that the
problems such as behavioural problems (60.9%), mixed group had greater dysfunction than the writing
neurotic traits (54.3%), history of developmental group in incorrect use of capital letters, division and
problems (39.1%) and family history of learning graded subtraction. Also, the mixed disorder and
GLVDELOLWLHV7KHVSHFL¿FHUURUVLQWKHLUUHDGLQJ
DQGZULWLQJVNLOOVZHUHGLI¿FXOW\LQFRPSUHKHQVLRQ
RPLVVLRQ RI ZRUGV GLI¿FXOW\ XVLQJ SKRQHWLF FXHV
GLI¿FXOWLHVZLWKVSHOOLQJVWHQVHVJXHVVLQJDWZRUGV
mispronunciation, substitution of letters, illegible
KDQGZULWLQJDQGYLVXRVSDWLDOGLI¿FXOWLHV
Neuropsychological Aspects of Learning
Disabilities in India:
Bhasi, Rao and Oomen (2003) studies the
effect of neuropsychological intervention on children
ZLWK 6SHFL¿F /HDUQLQJ GLVRUGHU IRU$ULWKPHWLF7KH
reading disorder groups had greater dysfunction than
the writing group in speech and language. Intellectual
function and mental balance on the PGI memory
scale were more affected in the mixed group in
comparison to the writing group. The study indicated
that subtypes of learning disorders differ in the or
QHXURSV\FKRORJLFDOSUR¿OHRIGH¿FLWVZLWKWKHPL[HG
group having greater dysfunction.
Kumar and Bhasi (2009) compared matched
groups of adults with history of LD (n=22) and
normals (n=25) using the Wechsler Adult Intelligence
study was carried out in two phases. In Phase I norms
were developed for the Test of Arithmetic Ability
(Shalev et al., 1993), administering it to a sample of
284 children studying in Standards III to VI. Standard
ZLVHFXWRIIVFRUHVZHUHGHYHORSHGWRLGHQWLI\6SHFL¿F
Learning Disorder for Arithmetic. In Phase II, a
remedial program consisting of neuropsychological
remediation targeting the functions of attention,
visual and verbal memory as well as content
based arithmetic skills training was developed for
WKH WUHDWPHQW RI 6SHFL¿F /HDUQLQJ 'LVRUGHU IRU
$ULWKPHWLF $ VDPSOH RI  FKLOGUHQ ZLWK 6SHFL¿F
/HDUQLQJ 'LVRUGHU IRU $ULWKPHWLF ZHUH LGHQWL¿HG
using the NIMHANS Index for SF=LD, of which the
treatment group comprising of 10 children received
neuropsychological remediation while the control
group comprising of 7 children received remedial
sessions for the improvement of handwriting skills.
Both the groups receive content based remediation
of arithmetic skills after they were regrouped based
RQ WKH QDWXUH RI DULWKPHWLF GH¿FLWV DV VHHQ RQ WKH
Test of Arithmetic Ability. Results indicated a
VLJQL¿FDQW LPSURYHPHQW LQ DULWKPHWLF VNLOOV LQ WKH
treatment group suggesting that neuropsychological
remediation contributes to the improvement of
arithmetic skills.
Kohli, Malhotra, Khehra and Kaur (2005)
DLPHGWRDVVHVVWKHGH¿FLWVDQGQHXURSV\FKRORJLFDO
IXQFWLRQLQJ LQ FKLOGUHQ ZLWK VSHFL¿F OHDUQLQJ
disability drawn from the clinic population of the
Child and Adolescent Psychiatric Clinic at PGIMER,
Chandigarh. 35 children in the age range of 7-14
years were assessed using the NIMHANS Index of
6SHFL¿F /HDUQLQJ 'LVDELOLWLHV 0DOLQ¶V ,QWHOOLJHQFH
Scale for Indian Children, and the PGI Memory Scale
68
6FDOH ,,, :$,6 ,,, 5HVXOWV VKRZHG D VLJQL¿FDQW
difference in Full Scale, Verbal and Performance IQs,
with normals obtaining higher scores. The adults
with history of LD also had lower scores on Verbal
IQ compared to Performance IQ. Analysis of index
VFRUHVLQGLFDWHVVLJQL¿FDQWGLIIHUHQFHLQWKHLQGLFHV
of Verbal Comprehension, Perceptual Organization
and Working Memory between the two groups with
QR VLJQL¿FDQW GLIIHUHQFH LQ WKH LQGH[ RI 3URFHVVLQJ
Speed. In addition, a positive correlation was found
between the three indices of Verbal Comprehension,
Perceptual Organization and Working Memory with
the Full Scale IQ, Verbal IQ and Performance IQ in the
adults with history of LD group while in the normals,
positive correlation was found between the Full Scale
IQ and all the four index scores, between Verbal
IQ and the indices of Verbal Comprehension and
Working Memory as well as between Performance
IQ and the indices of perceptual organization,
working memory and perceptual speed. These results
VXJJHVWWKDWWKHQHXURSV\FKRORJLFDOSUR¿OHRIDGXOWV
with history of LD vary from that of normal controls.
Krishna, Oomen and Rao (2008), aimed
to examine the association between academic
VNLOO GH¿FLWV EUDLQ G\VIXQFWLRQ LQ WKH IRUP RI
QHXURSV\FKRORJLFDO GH¿FLWV DQG SV\FKRORJLFDO
comorbidity in the form of behavioral/emotional
problems. The study was done on a sample of 130
school going children with learning disability,
studying in the 3rd to the 7th std in English medium
schools. The tools used were the Sociodemographic
GDWD VKHHW 1,0+$16 ,QGH[ IRU 6SHFL¿F /HDUQLQJ
Disabilities- Level II- Short scale, NIMHANS
Neuropsychological Battery for Children, Missouri
Assessment for Genetics Interview for Children-
 Annie John / Practice guidelines : Learning Disability
Parent Version and the Malins Intelligence Scale Sadasivan et al. (2009) compared the effect
for Indian Children. There was a higher frequency of phonological awareness intervention (PA) and
of mixed disabilities than single disabilities. The neuropsychological intervention (NP) in two groups
QHXURSV\FKRORJLFDO GH¿FLWV VKRZHG SUHGRPLQDQWO\ of 10 reading disabled children each (10-13 years).
GLIIXVH FRUWLFDO GH¿FLW SDWWHUQ DQG WKH EHKDYLRUDO The children with reading disability were also
emotional problems were predominantly compared in performance on reading, phonological
externalizing symptoms with ADHD having the and neuropsychological tests with twenty age-
highest frequency. Associations between academic and education-matched controls without reading
VNLOO GH¿FLWV DQG QHXURSV\FKRORJLFDO GH¿FLWV ZHUH disorder. Both the reading disabled groups received
evident as an increased number of impaired academic intervention in 20 bi-weekly sessions of 40 minute
GRPDLQVZHUHDVVRFLDWHGZLWKDFDGHPLFVNLOOGH¿FLW duration. The PA group receive inputs to enhance
VHYHULW\DQGJUHDWHUQHXURSV\FKRORJLFDOGH¿FLWV7KH phonological awareness skills such as segmentation,
behavioral/emotional problems were predominantly isolation, deletion and tracking of speech sounds
externalizing symptoms with ADHD having the using games and visual material. The NP group on the
highest frequency. Associations between academic other hand received inputs to enhance their attention,
VNLOO GH¿FLWV DQG QHXURSV\FKRORJLFDO GH¿FLWV ZHUH concentration, working memory, verbal learning
evident as an increased number of impaired academic strategies, planning and organization and memory
GRPDLQV DVVRFLDWHG ZLWK DFDGHPLF VNLOO GH¿FLW skills. The results indicated that reading disabled
VHYHULW\DQGJUHDWHUQHXURSV\FKRORJLFDOGH¿FLWV7KH FKLOGUHQGLIIHUHGVLJQL¿FDQWO\IURPWKHFRQWUROJURXS
behavioral/emotional problems were found to be on reading abilities, attention, executive functions
QRQVSHFL¿FWRWKHW\SHRIDFDGHPLFVNLOOGH¿FLWV7KH and phonological awareness measures at phoneme
and syllable levels before intervention was carried
association between all three dimensions was seen by
out. After intervention, both treatment groups
WKH IRUPDWLRQ RI  FOXVWHUV ZLWK GLVWLQFW SUR¿OHV RI
VKRZHG VLJQL¿FDQW LPSURYHPHQWV LQ WKHLU UHDGLQJ
DFDGHPLF VNLOO GH¿FLWV QHXURSV\FKRORJLFDO GH¿FLWV
score which was maintained three months after the
and behavioral/emotional problems. The authors
intervention. Cognitive changes and phonological
attributed this association to brain dysfunction.
processing skills showed different outcomes in
Interventions in Learning Disabilities in India: response to intervention. While the PA group had
Rozario, Kapur and Rao (1994) evaluated improved attention, verbal and visual memory and
effectiveness of a 25 session remedial package visual perception, the NP group had enhanced verbal
for 25 children (9-11 years) with LD and reported ÀXHQF\ LQKLELWLRQ FRQWURO YHUEDO OHDUQLQJ DQG
VLJQL¿FDQWLPSURYHPHQW immediate visual memory. phonological awareness
DW SKRQHPH OHYHO LPSURYHG VLJQL¿FDQWO\ DIWHU 3$
Srikanth and Karanth (2003) developed a
intervention while the improvement for the NP group
remedial programme based on the Aston Teaching
was at the syllable level. The improvements were
Programme focusing on auditory visual channel
maintained at three month follow-up for both groups
GH¿FLWV VSHFL¿F VSHOOLQJ UXOHV DQG FXHV WUDLQLQJ
ZLWKWKH3$JURXSEHLQJVLJQL¿FDQWO\KLJKHUWKDQWKH
in comprehension skills, oral expression, written
NP group on verbal working memory while the NP
expression and visuo-motor perceptual skills. The JURXSZDVVLJQL¿FDQWO\KLJKHURQYHUEDOÀXHQF\WKUHH
remedial programme included both reading and months after intervention. The two interventions were
VSRNHQODQJXDJHSUR¿FLHQF\ found to be effective in enhancing reading accuracy
Pagedar and Sarnath (2008) developed the LQDJURXSRIFKLOGUHQZLWKVSHFL¿FUHDGLQJGLVRUGHU
PASS Reading Enhancement Programme (PREP), In addition, the two interventions also improved
a theory driven remediation program for primary VSHFL¿FFRJQLWLRQVZKLFKZHUHPDLQWDLQHGRYHUWLPH
VFKRROFKLOGUHQZLWKGLI¿FXOW\LQUHDGLQJVSHOOLQJDQG
ASSESSMENT OF SLD
comprehension. This programme aims at improving
The assessment of SLD by a Clinical
information processing strategies and avoids direct
Psychologist allows the clinician to:
blending. Pilot study on effectiveness of PREP with x
teaching of word skills like phoneme segmentation/

6 students aged 7-11 years referred to Maharashtra x

Make a diagnosis of SLD

x
Understand the severity of the disability
Dyslexia Association’s Resource Centres. &RQVWUXFWDOHDUQLQJSUR¿OHRIWKHFKLOG

69
 Annie John / Practice guidelines : Learning Disability
x
Make recommendations for specialized Information Processing:
instructions and accommodations for the child
The main purpose of determining if a child has
a SLD is to be able to provide appropriate, supportive
and remedial programmes to enable the child to
effectively function in his or her environment. As
SLD affects all spheres of functioning – academic,
emotional and social – it is necessary to provide a
FRPSOHWHDQDO\VLVDQGSUR¿OHLQWKHVHDUHDV7KLVZLOO
in turn suggest the treatment and accommodations
WKDW WKH FKLOG ZLOO UHTXLUH :LWK D SUR¿OH RI VNLOO
GH¿FLWVDQGVWUHQJWKVWKHSURIHVVLRQDODGPLQLVWHULQJ
the remediation programme will be in a better
position to plan an effective programme.
The purpose of a diagnosis is not to provide a
label in order to categorize the child. But to provide
a basis for the child to be able to access support and
services to which she/he is entitled to.
Step 1:
GATHERING HISTORY OF THE CHILD.
x
This should include:
x
Developmental history
Educational history – including any
x
intervention used
(PRWLRQDODQGEHKDYLRXUDOGLI¿FXOWLHV
x
Classroom observation of learning behaviours
– if this is not possible, a descriptive report by
the teacher is recommended with the following
information
- does the child pay attention to classroom
instruction, does the child follow classroom
instruction
- homework compliance
- organization of behaviour – is the child ready
x
for the class with books, stationary, etc.,
Social interaction with peers and adults
Step 2:
STANDARDIZED ASSESSMENTS
x
Cognitive Ability:
Assessment of cognitive ability should be made
appropriate, to ensure that the child’s score x
using a test that is both valid and culturally
test should be administered in the language x
falls within the average range of scores. The
the child is most comfortable in. Acceptable
measures include, but are not limited to Malins
Wechsler Intelligence Scale for Children-IV x
Intelligence Scale for Indian Children (1971),
(2003) and the Stanford-Binet.
70
x
Different aspects of information processing
should be assessed on a general basis, and
LQ GHSWK EDVHG RQ WKH GLI¿FXOW\ UHSRUWHG LQ
the referral. Auditory and visual processing,
processing speed, executive functioning,
memory – sequential, short term and long term
and auditory and phonological awareness must
EHDVVHVVHG7KHDVVHVVPHQWRIJURVVDQG¿QH
motor skills – balance, eye- hand co-ordination,
pencil grip and sense of rhythm. The assessment
should be done in the language the child is
most comfortable in. Some of the measures
of cognitive ability do measure some aspects
of information processing as well (WISC-
IV), however the assessment of skills like
phonological awareness, are included in tools
that measure reading.
x
Achievement:
Assessment of skills necessary for learning
in the classroom must be made. These can
be categorized into 3 main areas – reading,
writing (including spelling) and mathematics.
Assessment tools that commonly used include
the NIMHANS Battery (2002), Wechsler
Objective Reading Dimension (1993),
Wechsler Objective Numerical Dimension
(1996), Test of Written Language-III (1996),
Woodcock Johnson Tests of Achievement
(2001).
x
The Assessment of Reading should include:
,GHQWL¿FDWLRQ RI DOSKDEHWV DQG NQRZLQJ WKH
x
sounds of letters in the early years.
Words in isolation – analysis of the kind of
GLI¿FXOWLHV SUHVHQW ZKLOH UHDGLQJ D ZRUG
including decoding strategies, these could
include substitution, omission or addition of
consonants or vowels, phonetic inaccuracies,
reversal or inversion of letters or parts of
words, knowledge of patterns of sound made
by a group of letters (eg., ‘ough’ in ‘rough’)
and familiarity with a homophones.
Reading for meaning from a sentence or
passage.
Fluency in reading – is the child reading the
text in a word by word, phrase by phrase
manner with pauses that do not contribute to
the meaning of the text.
Does the child ignore punctuation while
reading.
 Annie John / Practice guidelines : Learning Disability
x
x
Understanding written directions. included or when information is given out of

x
Middle school and high school students should sequence.
be assessed for reading rate. Ability to explain and communicate about

x
math, including asking and answering question.
x
The Assessment of Writing should include:
x
Ability to read texts to direct own learning.
x
Proper pencil grip.
Ability to retrieve alphabets representing Ability to remember assigned values or
GH¿QLWLRQVLQVSHFL¿FSUREOHPV
x x
sounds.
The formation and legibility of letters or Mental fatigue or being overly tired when
doing math or feel overloaded when faced with
x
numbers.
x
A mixture of print and cursive the appearance a worksheet full of math exercises.

x
of upper case in the middle of a word should Confusion with learning multi-step procedures.
Ability to order the steps used to solve a
x
also be noted.
x
Spelling – words in isolation – with a detailed problem.

x
error analysis, for example, substitution, Ability to copy problems correctly.

x
omission or addition of consonants or vowels, Ability to read the hands on an analog clock.
phonetic inaccuracies, sequencing or letter Ability to interpret and manipulate geometric
FRQ¿JXUDWLRQV
x
RUGHUGLI¿FXOWLHVUHYHUVDORULQYHUVLRQRIOHWWHUV
knowledge of spelling rules, of commonly Ability to appreciate changes in objects as they

x
are moved in space.
x
used sight words and of homophones.
Spelling as part of comprehension or essay Ability to switch between multiple demands in

x
a complex math problem.
x
writing.
Ability to tell when tasks can be groped or
x
Punctuation.
Use of vocabulary and synonyms in a piece of merged and when they must be separated in a

x
multi-step math problem.
x
free writing.
Ability to present ideas in an understandable Ability to manage all the demands of a
complex problem, such as a word problem,
x
sequence.
Ability to present ideas in an understandable even thought he or she may know component
facts and procedures.
x
sequence.
Ability to plan and organize a written text for a Step 3:

x
particular audience or purpose. Behavioural Observation during assessment.
Organization of writing and the mechanics of Observation done in the testing situation should
x
writing a paragraph or essay. report on factors that could impact the learning of
Speed of writing.
x
the child. This should include.

x
The Assessment of Mathematics Skill should Level of anxiety.

x The ability to recall basic math facts, x

include: Fatigue.
Handwriting – pencil grip, pressure while

x Ability to maintain precision during x

procedures, rules, or formulas. writing, posture.
Ability to sustain attention during assessment.

x
mathematical work. While making a diagnosis it is essential to
Ability to sequence and carry out successfully UXOHRXWIDFWRUVOLNHODFNRIVXI¿FLHQWRUDSSURSULDWH

x
multiple steps. instruction. Response to Intervention methods tried
8QGHUVWDQGLQJ RI WKH ¿QDO JRDO RI WKH PDWK out in the early years (Kindergarten onwards) should

x
problem. be noted. Here, the child should have had some
Ability to identify salient aspects of a specialized or intensive remedial instruction in the
mathematical situation, particularly in word VSHFL¿FDUHDRIGLI¿FXOW\EHIRUHDGLDJQRVLVRI6/'
problems or other problem solving situations is done. This intervention could have been carried out

x
where some information is not relevant. by a special educational teacher or in the form of a
Ability to remember and understand the one to one instruction by a tutor. If the child has not
PDGHVXI¿FLHQWSURJUHVVDIWHUKDYLQJKDGVSHFLDOL]HG
x
vocabulary and language of math.
Ability to know when irrelevant information is help at the time assessment is carried out, then a

71
 Annie John / Practice guidelines : Learning Disability
diagnosis of SLD can be considered. It is necessary
WRUXOHRXWWKHIDFWWKDWWKHDFDGHPLFGLI¿FXOWLHVVHHQ
are not a result of poor or inadequate educational
methods.
The assessment should provide evidence for
the fact that the child’s learning and performance in
WKH DUHDV DVVHVVHG DUH VLJQL¿FDQWO\ ORZ LQ FRQWUDVW
to other areas of functioning. That performance in
VFKRRO LV VLJQL¿FDQWO\ OLPLWHG GXH WR WKH GLVDELOLW\
and that the child is unable to access the school’s
FXUULFXOXPGXHWRWKHVSHFL¿FGLVDELOLW\
The Clinical Psychologist should be aware of
the fact that the severity and manifestation of SLD
can vary across and within the pertinent areas. The
GHJUHH DQG H[WHQW WR ZKLFK WKH VSHFL¿F GLVDELOLW\
impacts on the child’s learning should be describe as
this will enable the educator to make an Individual
Educational Plan.
The Clinical Psychologist should be cognizant
of the fact that age and stage of development of the
FKLOGFDQLQÀXHQFHWKHPDQLIHVWDWLRQRIWKHGLVDELOLW\
7KHPDQLIHVWDWLRQFDQDOVREHLQÀXHQFHGE\WKH
As many children who come for assessment
are from schools and backgrounds where English is
QRWWKH¿UVWODQJXDJHRILQVWUXFWLRQLWLVLPSRUWDQWWR
be able to assess them in the language they are most
comfortable in.
DIAGNOSIS OF SLD
A diagnosis can be made based on the results
of the assessments carried out. The child could
have a Reading, Spelling, Writing, or Arithmetic
Disability or a combination of any of the above. The
WHUP '\VOH[LD XVXDOO\ UHIHUV WR D VSHFL¿F GLVDELOLW\
LQ UHDGLQJ EXW VSHOOLQJ GLI¿FXOWLHV DUH DOVR RIWHQ
LQFOXGHG'\VJUDSKLDUHIHUVWRDVSHFL¿FGLVDELOLW\LQ
writing and in expressing oneself in writing. Visual
DQG $XGLWRU\ 3URFHVVLQJ 'LI¿FXOWLHV FRXOG DOVR
contribute to a SLD.
The traditional criterion of diagnosis of SLD
was based on whether the child’s scores showed a
discrepancy between ability and achievement, usually
assessed by comparing the child’s IQ with the levels
attained on an achievement test. While this approach
to the diagnosis of SLD allows the clinician to report
D VLJQL¿FDQW GHOD\ LQ D VWXGHQW¶V DFKLHYHPHQW DV
compared to ability, researchers have argues that
context that the disability is seen in – in an academic
or nonacademic setting. (NJCLD, 1998).
The National Academy of Neuropsychology
(NAN) Policy and Planning Committee recommends
that when a learning disability is suspected, an
evaluation of neuropsychological abilities is
QHFHVVDU\ WR GHWHUPLQH WKH VRXUFH RI WKH GLI¿FXOW\
as well as the areas of neurocognitive strength
that can serve as a foundation for compensatory
strategies and treatment options. The purposes of a
neuropsychological evaluation are to determine the
pattern of brain-related strengths and weaknesses,
to develop an understanding of the nature and
RULJLQRIWKHGLI¿FXOWLHVWRPDNHDGLDJQRVLVDQGWR
SURYLGH VSHFL¿F UHFRPPHQGDWLRQV IRU DSSURSULDWH
intervention and treatment.
When possible it is recommended to use
standardized measures. Standardized tests allow
clinicians and other professionals working with the
FKLOGWRXQGHUVWDQGWKHQDWXUHRIGLI¿FXOWLHVSUHVHQW
When standardized achievement tests are not
available, curriculum based assessments should
be used. Here it is important to be aware that the
assessment should be comparable with the child’s
present educational curriculum.
72
PDQ\ÀDZVH[LVWLQWKLVPRGHO9DXJKQHWDO
In India, the discrepancy model should be used with
caution as it does not account for those students who
KDYHQRWKDGVXI¿FLHQWH[SRVXUHWRDGHTXDWHOHDUQLQJ
experiences, or recommended learning strategies.
For this reason it is necessary to make sure that the
VWXGHQWEHLQJDVVHVVHGKDVKDGDWOHDVW\HDUVRI
DGHTXDWH VFKRROLQJ EHIRUH D GLDJQRVLV LV PDGH It
also excludes those children with high abilities who
have developed strategies to compensate for their
GLI¿FXOWLHV
,I WKH FKLOG LV LQ SUHVFKRRO RU LQ WKH ¿UVW
two years of schooling, the ability-achievement
discrepancy model will not allow a diagnosis. In such
cases, a Response to Intervention model is to be used.
The assessment by the Clinical Psychologist in such
FDVHVVKRXOGJLYHDSUR¿OHRIWKHVNLOOVRIWKHFKLOG
ZLWK VSHFL¿F UHFRPPHQGDWLRQV IRU WKH LQWHUYHQWLRQ
RIWKHVHGLI¿FXOWLHV7KHLQWHUYHQWLRQFRXOGEHFDUULHG
out by a special educator, the teacher in the class,
trained parents or any other trained caregiver. It is
important to note and worthy of repetition that when
the child has had these special methods of instruction
for a period of 2 years and the symptoms of SLD
persist, a diagnosis of SLD should be considered. As
a complete discussion of the Response to Intervention
 Annie John / Practice guidelines : Learning Disability
model cannot be presented here, it is recommended
that the Clinical Psychologist read the chapter on
Remedial Training Programmes with SLD.
The assessment carried out by the Clinical
3V\FKRORJLVWVKRXOGEHVSHFL¿FDQGGHWDLOHGHQRXJK
to provide an idea of the severity and type of SLD.
)RU LQVWDQFH LI WKH VWXGHQW KDV D VSHFL¿F UHDGLQJ
disability, it is essential to be able to say whether
WKHUHDGLQJGLVDELOLW\LVGXHWRDSKRQRORJLFDOGH¿FLW
RUDYLVXDOSHUFHSWXDOGH¿FLW7KLVDOORZVDVSHFL¿F
intervention plan that is based on research evidence
to be followed.
The assessment should also allow the educator
WRFRQVWUXFWDOHDUQLQJSUR¿OHRIWKHFOLHQWWKDWZRXOG
indicate areas of strength as well as needs.
'LIIHUHQWLDO'LDJQRVLVIRU6SHFL¿F/HDUQLQJ
Disability:
What is Differential Diagnosis?
Differential diagnosis refers to the process by
which a disorder or a presenting set of symptoms is
evaluated and differentiated from other conditions
that may by associated with similar clinical features.
It requires the formulation of hypotheses regarding
VRFLDO FKDUDFWHULVWLFV DQG VXI¿FLHQW LQWHJUDWLRQ RI
other assessment information.
When one of several factors may be the
cause of learning problems, low achievement,
underachievement or maladaptive behavior, all
possible etiological alternatives must be considered.
Intellectual limitations, sensory impairments
and adverse emotional, social and environmental
conditions may be the primary cause of low
achievement and should not be confused with
learning disabilities.
Documentation of underachievement in one or
PRUHDUHDVLVDQHFHVVDU\EXWLQVXI¿FLHQWFULWHULRQIRU
the diagnoses of learning disabilities.
Discrepancy formulas must not be used as the
only criterion for the diagnosis of learning disabilities.
Manifestations of learning disabilities such
as language impairment, can affect performance on
intelligence tests. Selection of tests and interpretation
RIUHVXOWVPXVWDFNQRZOHGJHWKHLQÀXHQFHRIVSHFL¿F
disabilities on intelligence measures.
What LD does not include:
The Individuals with Disabilities Education
the etiology and nature of the presenting problem
(NJCLD, 1994).
The clinician must be aware that Learning
Disabilities often occur in conjunction with other
disorders or conditions. The assessment process
should establish that while LD can co-exist with
other conditions such as ADHD, depression, anxiety,
VRFLDOVNLOOGH¿FLWVODQJXDJHGLVRUGHUVHWFLWLVQRW
primarily a result of the co-morbid disorder.
Prerequisites for Differential Diagnosis:
A comprehensive assessment is a prerequisite
for differential diagnosis. NJCLD recommendations
suggest that assessment for LD must include
procedures to establish levels of performance in the
areas of motor, sensory, cognitive, communication
and behavior functioning.
7KHWHVWVXVHGPXVWGHPRQVWUDWHWKDWVLJQL¿FDQW
GLI¿FXOWLHVSHUVLVWLQRQHRUPRUHSURFHVVHVLQYROYHG
in the acquisition, retention, organization and use
of listening, speaking, reading, writing, reasoning
and numerical skills. Tests should also indicate the
H[WHQWWRZKLFKWKHVHSURFHVVLQJGH¿FLWVLPSDLUWKH
individual’s ability to learn.
In addition to test scores there has to be an
adequate consideration of individual behavioral and
73
$FW,'($VSHFL¿HVWKDW±6SHFL¿F/HDUQLQJ
Disability does not include learning problems that
are primarily the result of visual, hearing or motor
disabilities, of mental retardation, of emotional
disturbance, or of environmental, cultural or
economic disadvantage.
,QPDNLQJDGLDJQRVLVRID6SHFL¿F/HDUQLQJ
Disability, the clinician would need to rule out:
1. Mental retardation- all domains of development
are delayed.
2. Pervasive development disorder- delays seen
in 2 or more domains of development.
3. Autism- impaired language and communication,
impairments in social and emotional
functioning, with or without mental retardation.
4. Primary language disorder- language
development outside the normal range and
VLJQL¿FDQWO\ XQGHUGHYHORSHG FRPSDUHG WR
nonverbal reasoning in normal range.
 6ORZ /HDUQHU GHYHORSPHQWDO SUR¿OH
consistently at lower end of normal range, IQ
scores are below average range.
 3ULPDU\VHQVRU\GH¿FLWVYLVXDOPRWRUKHDULQJ
and speech impairments.
7. Environmental factors such as deprivation,
abuse, inadequate or inappropriate instruction,
 Annie John / Practice guidelines : Learning Disability
socioeconomic status or lack of motivation.
The clinician must be aware that SLD often
occurs in conjunction with other disorders or
conditions. The assessment process should establish
that while SLD can and often does co-exist with
other conditions such as AD/HD, depression, anxiety,
VRFLDOVNLOOGH¿FLWVODQJXDJHGLVRUGHUVHWFLWLVQRW
primarily a result of the co-morbid disorder.
Importance of Differential Diagnosis:
A comprehensive and thorough assessment is critical
for a differential diagnosis. Diagnostic accuracy has
implications for prognosis and planning appropriate
intervention programmes. In addition it may also
indicate the need for referrals to other professional
services that may be of use to the intervention
programme.
Referrals Required:
These are a possible list of referrals that the
clinician would need to make either in the course
of establishing a diagnosis or when planning an
LQWHUYHQWLRQ SURJUDPPH IRU D 6SHFL¿F /HDUQLQJ
Disability.
Audiologist – LI WKHUH DUH GLI¿FXOWLHV REVHUYHG LQ
hearing.
Speech Therapist – LI WKHUH DUH VSHHFK GLI¿FXOWLHV
such as stammering, lisping, stuttering etc.
Ophthalmologist±LIWKHUHDUHGLI¿FXOWLHVLQUHDGLQJ
from text – holding text too close or too far, errors in
copying from the black board, squinting, blurring of
vision, frequent headaches etc.
Neurologist – LI WKHUH DUH GLI¿FXOWLHV LQ JDLW
movement, unusual pencil grip, presence of soft
neurological signs, presence of seizure history,
physical discomfort and fatigue while writing.
Peadiatrician - to monitor for general health, age
appropriate milestones and physical development.
To rule out hormonal imbalances and abnormalities
in thyroid, iron and haemoglobins levels and
functioning.
Occupational Therapist - to aid in intervention for
GLI¿FXOWLHVREVHUYHGLQJDLWPRYHPHQWYLVXDOPRWRU
coordination, handwriting.
Child Psychiatrist - possible pharmacological
intervention for co-morbid AD/HD, other emotional
and behavioural disorders should be considered.
COMMUNICATING A DIAGNOSIS OF SLD
The Assessment Report:
Most often the report is read by non
74
psychologists, i.e., parents and special educators –
for this reason it is important to keep the language
simple and clear. If possible, give a brief description
of the assessment tool used. Be aware that the
special educator will be making an IEP based on the
assessment report.
A typical report can be detailed under the
following sections. Examples of reports are provided
in the Appendix.
Reason for Referral:
Although this may seem obvious, it is important
to note why the child is being assessed. Whether the
child was referred for assessment by the teacher or
the parent will give an indication of the awareness of
the caregiver concerned.
Educational History:
Has the child been through different school
systems. What was the method used to teach reading?
Has the child had any sort of intervention and for
what period of time.
Personal History:
$Q\VLJQL¿FDQWHYHQWVLQWKHSHUVRQDOKLVWRU\
of the child that might have contributed to the present
situation, including psychosocial factors.
Previous Assessments:
What previous assessments have been done
and the results in brief.
Behavioral Observation:
Include observation of behavior during
the testing situation and observation done in the
classroom.
Assessment Tools Used:
List out the name of the tools. You can describe
WKHPEULHÀ\ZKLOHJLYLQJWKHUHVXOWV
Results:
Give values if the tests are standardized, give
SRVLWLYHDQGQHJDWLYH¿QGLQJV±DOOKHOSWRIRUPXODWH
the educational plan.
Discussion of Findings:
Give a clear idea of how you arrived at your
¿QGLQJVDQGWKHLPSOLFDWLRQVIRULQWHUYHQWLRQ
Recommendations (and accommodations):
Based on the assessment, the Clinical
Psychologist should give recommendations to the
special educator and recommend accommodations
in the classroom and for examinations. The educator
 Annie John / Practice guidelines : Learning Disability
and the caregiver must be given clear and detailed groups and courses.
instructions on how to proceed with the interventions 9. Encourage building good communication links
suggested. For instance, if the child has an auditory with the school and the child’s teachers.
SURFHVVLQJ GLI¿FXOW\ WKH &OLQLFDO 3V\FKRORJLVW FDQ 10. Help the parent be aware of their own
recommend that the child be seated (in the classroom) psychological needs and mental health
away from distracting sounds (away from the door as coping with their child’s learning and
RUZLQGRZ6SHFL¿FVXJJHVWLRQVOLNHWHFKQLTXHVRU emotional needs can be stressful process.
WRROVWRVXSSRUWWKHFKLOGZLWKWKHSDUWLFXODUGH¿FLW 11. Emphasis that early intervention, teaching
must be made. The details in the recommendations skills of organization of time management at
also help the board to decide if the child must be home, does provide a critical scaffold for the
given an accommodation at the time of examinations. child.
12. The acceptance of LD is an ongoing process
Information Conveyed to Parents:
and each developmental stage presents its own
Being informed that their child’s assessment
challenges.
indicates the presence of SLD can be a challenging
13. The presence of SLD does not limit what the
process of acceptance for parents. Apart from
child will achieve their adult and professional
informing them of the diagnosis, the clinician has
lives given the appropriate support and
to handle the session and information given with
intervention.
great sensitivity and empathy. Some parents are
relieved in knowing that their concerns about their Talking to the Child:
child’s academic performance are rooted in a genuine Often the child referred for assessment is
disability and for others it is an ongoing process forced to assume a passive role and is taken for
of coming to terms with the diagnosis and being various tests without necessarily being told about
engaged in the intervention. These are a few points what is happening or what the test results indicate.
that the clinician would need to be aware of while The child may experience a sense of low personal
discussing the diagnosis of SLD and its implications. control and could become apprehensive about what
1. Avoid the use of jargon and convey assessment the process is going to reveal. Engaging with the
information with clarity. child at all levels in the assessment and intervention
2. Give the parent time to go through the process is essential.
assessment report and be able to raise queries. Parents may sometimes have concerns about
3. Be factual and accurate in discussing the whether the child needs to be ‘burdened’ with the
assessment results. knowledge of his/her SLD. They need to be informed
4. Emphasis that while SLD is a life long by the Clinical Psychologist that talking to their child
condition, the consistent use of strategies have about SLD encourages them to be more positive in
been proven to enhance coping and maximize their approach to academics.
abilities and experiences of success. Prior to the assessment the Clinical
5. Recognize and acknowledge feeling of guilt, Psychologist should establish a rapport with the child
anger, blame, denial, anxiety and loss in and be able to explain the rationale for testing.
coming to terms with the diagnosis.
Sentences like, µWKLVWHVWLQJZLOOKHOSXV¿QGRXW
6. Emphasis that the child is more than a
your areas of strength and what areas you need help
diagnosis, identify their areas of strength and
with’ or ‘you did tell me that you found reading very
nurture them.
GLI¿FXOW7KHWHVWVWKDWZHZLOOEHGRLQJZLOOKHOSXVWR
7. Encourage them to talk to their child and family
¿QGRXWZK\DQGZKDWZHFDQGRWRKHOS¶ conveys a
members in an open manner about SLD. This
sense of reassurance for the child.
conveys to the child that it is not ‘shameful’
to have SLD and that it is an eminently The Clinical Psychologist must provide
manageable issue. information that is age appropriate and encourage
8. Provide parents with information that would the child to raise question/ concerns about the testing
extend their understanding of SLD. This process and the results.
could be relevant literature and research, The child may feel relieved to know that
online resources, books, parent support struggling in school is not their fault, that there

75
 Annie John / Practice guidelines : Learning Disability
LV D UHDVRQ ZK\ WKH\ ¿QG VFKRRO KDUG DQG PRVW use of instructional time, provide multiple learning
importantly that they can do something about it. opportunities, and employ a variety of assessments.
The Clinical Psychologist should provide age A Model Intervention Programme:
appropriate information in sharing assessment results An effective remedial reading programme
with the child. PXVW DGGUHVV WKH VWXGHQW¶V VSHFL¿F VWUHQJWKV DQG
The child should be encouraged to see that weakness, instructional sequences, provide ample
different children learn differently and that the practice opportunities and must include targeted
SUHVHQFH RI D GLI¿FXOW\ GRHV QRW LQGLFDWH SHUVRQDOVFLHQWL¿FDOO\EDVHGLQVWUXFWLRQDOVWUDWHJLHV
failure. Most educators working with children with
The need to use strategies consistently should SLD chalk out what are known as Individual
be stressed upon. They should also be made aware Educational Plans (IEP’s) for each child based
that the proper use of strategies while being effective RQ WKH GH¿FLW SUR¿OH DQG WKH FXUUHQW IXQFWLRQLQJ
and transforming the way they learn, will mean that capabilities of the child. The aim of these IEP is to
they may spend more time on learning. provide one with a working framework to operate in
The child and parents should be encouraged for each child. In addition, periodic evaluation of the
to expand their understanding of SLD through child’s current level of functioning occurs within this
reading up relevant literature/websites and mutually IUDPHZRUNWRKHOSUHHYDOXDWHQHHGHI¿FDF\RIWDVNV
discussion information. for the child based on response to intervention.
The programme should also include assessment
Intervention: strategies for diagnosing student needs and measuring
Remedial training is the main form of progress, as well as a professional development plan
intervention for the child and is planned based that ensures teachers have the skill and support
RQ WKH SUR¿OH HVWDEOLVKHG WKURXJK DVVHVVPHQW necessary to implement the program effectively and
Supportive psychosocial counseling and social skills to meet the needs of individual students.
training should also be considered for a child with
Some Questions to ask About the Remedial
SLD. Several different remedial training methods
Program
are available but only a few of them are tested
Here are some questions you need to ask about
VFLHQWL¿FDOO\7KHIROORZLQJDUHVRPHJXLGHOLQHVRQ
the child’s remedial program:
the qualities of an effective training method.
1. What is the name of the remedial program?
7KH ¿UVW VWHS LQ HYDOXDWLQJ WKH HI¿FDF\ RI 2. Is it research-based? Does the program include
a remedial training programme is to identify who the essential elements?
the training is meant for. The next important thing 3. How many children will be in the group?
is to assess who will provide the training- is it a 4. How have the children in the group been
special educator, teacher, speech-language therapist selected?
or educational/clinical psychologist? Finally, it is 4. Has the trainer been trained in direct,
important to assess the time frame involve and the systematic, multisensory instruction?
support the remedial program offers even after the  ,V WKH WUDLQHU FHUWL¿HG LQ WKLV SDUWLFXODU
completion of the programme. program?
Qualities of Effective Intervention Programs: 6. How many hours of instruction per week will
Effective programs must be driven by research, each child receive?
not ideology. 7. How will the pace of the instruction be
determined?
Effective programs emphasize direct, 8. What criteria will be used to determine
systematic, intensive, and sustained changes in the mastery?
target behaviour/cognition. 9. How will the parents be informed about the
Effective programs need to be supported child’s progress?
by initial professional development and extended Directions for Remedial Instruction
follow-up training throughout the school year. 1. Introduce the child gradually to the programme
Effective programs should make effective 2. Start at a level that is comfortable for the child

76
 Annie John / Practice guidelines : Learning Disability
e.g. when blending sounds, start by introducing environment. Therefore, schools catering to
sounds of consonants and short vowel sounds. children from lower SES need to provide more
Then proceed to introducing consonant blends reading opportunities.
DQG¿QDOO\YRZHOEOHQGV 4. 0RWLYDWLRQDQG&RQ¿GHQFH – Good remedial
3. Stress on accuracy and not speed. training programmes trend to give immediate
4. Don't skip any stage in the intervention feedback to students that they are improving,
programme. DQG FDQ EH XVHG DV D FRQ¿GHQFH EXLOGHU DV
5. Provide adequate practice drills at each level. well.
6. Use concrete associative aids.
For any programme to be considered effective,
Components of an Effective Response to it must bring about changes in day-day behaviours.
Intervention Model: These include generalization as seen in better
1. Baseline Data – using curriculum-based academic performance and the ability of the child to
measurement as primary data gathering. gradually become an independent learner.
 0HDVXUDEOH 7HUPV ± GH¿QH SUREOHP DUHDV )LQDOO\ WKH HI¿FDF\ RI WKH SURJUDPPH DOVR
numerically. brings about change in behavior, emotional and
 $FFRXQWDELOLW\ 3ODQ ± PRQLWRU ¿GHOLW\ RI social aspects as these are found to be affected in this
selected intervention. population.
4. Progress Monitoring – how, where, and when A detailed programme for intervention of
intervention results will be measured and SLD with Arithmetic Disability is provided in the
recorded. Appendix.
5. Data Based Decision Making – ongoing
Academic Accommodations for Students with
analysis of data to drive future intervention
SLD:
decisions.
Psychologists are required to be aware of the
,WLVUHFRPPHQGHGWKDWFKLOGUHQDUHLGHQWL¿HG VSHFL¿F DFFRPPRGDWLRQV SURYLGHG E\ WKH 1DWLRQDO
early in their school life (KG to Grade1) as response Examination Boards that are available to students
to intervention at an early stage has been shown to be with a diagnosed SLD and the procedures to obtain
more effective. the same. These accommodations allow students
Older children will require other needs like with SLD to demonstrate their knowledge of a
VRFLDOVNLOOVEHKDYLRXUDODQGHPRWLRQDOGLI¿FXOWLHVWR VXEMHFW LQ DQ H[DPLQDWLRQ ,W OHYHOV WKH SOD\LQJ ¿HOG
be addressed as well. for these students by providing extra time, a reader,
an amanuensis, or the choice of dropping a second or
4 Keys to Remediation:
third language. A study done at the Learning Disability
1. (FOHFWLF $SSURDFK – An eclectic approach
Clinic at the Sion Hospital in Mumbai, (Kulkarni,
capitalizes on the particular strengths of the
Karande, Thadani, Maru & Sholapurwala, 2006)
child. The program will depend upon the age,
shows that students with SLD who have used these
VNLOOOHYHO$QGQHXURGHYHORSPHQWDOSUR¿OHRI
DFFRPPRGDWLRQV KDYH SHUIRUPHG VLJQL¿FDQWO\ EHWWHU
the child.
than those with SLD who have not availed of them.
2. 7RS'RZQ6WUDWHJLHV – Intervention for learning
The national boards – Central Board for
disorders need to consider top down strategies.
Secondary Education and the Indian School
For example, development in various regions
&HUWL¿FDWHGRSURYLGHDFFRPPRGDWLRQVIRUVWXGHQWV
along the left temporal-parietal cortices is
diagnosed with SLD.
responsible for modulation the phonological
aspect of reading; from this ability develops the Some state boards – including Maharashtra, Kerala
ability to modulate sounds to the visual words and Karnataka provide accommodations as well.
from association areas. Common accommodations available are
3. 6RFLRHFRQRPLF 6WDWXV – According to Noble exemption from second and third languages and the
and McCandliss (2005), socioeconomic status provision of extra time for completion of tests and
(SES) is a very strong predictor of reading exams.
skills due primarily to the home literacy The use of a scribe/computer and / or reader

77
 Annie John / Practice guidelines : Learning Disability
by the student depends on the level of disability
exhibited by the student and is usually available on a
FDVHVSHFL¿FEDVLV
In each case it is essential to route requests
for accommodation through the student’s school.
A copy of the assessment is sent to the head of the
school who forwards this to the board with previous
academic reports and letter of recommendation.
Test reports submitted should be detailed and
also include previous academic reports of the student.
Universities in India have just begun to
recognize the existence and implications of SLD
and to the author’s knowledge a few state boards or
universities do provide accommodation. Karnataka
University has been known to consider SLD for
special accommodations. They require that the
student acquire a statement from NIMHANS every
year for the accommodations to be provided. Delhi
University, though recognizing SLD in its admission
process, does not have set procedures that can be
used to apply for special accommodations. Individual
cases have been known to receive second language
exemptions.
Appendix A
*LYHQ EHORZ DUH  H[DPSOHV RI UHSRUWV IURP
DVVHVVPHQWV DETAILED REPORT
Example 1:
CONFIDENTIAL PSYCHO-EDUCATIONAL
REPORT
Name : Date of Assessment:
Date of birth: Age:
SUMMARY OF FINDINGS
Abilities:
__________ is of high average general ability
(above that of 79% of his age group). He has high
verbal scores (91st percentile), and average nonverbal
scores (53rd percentile) and the difference between
WKHPLVVLJQL¿FDQW
Pattern of Relative Strengths and Weaknesses:
_________ can retain general knowledge facts
well, and his abstract verbal reasoning skills along
with common sense problem solving is good.
+HKDVGLI¿FXOWLHVZLWKDWWHQWLRQDQGLPSXOVH
control.
Attainments:
For reading accuracy and comprehension,
_________’s attainment is about two years below
expected level, while his spelling level is one year
below predicted level for age and ability. His
arithmetic ability is within the average range.
Conclusions:
________ shows a pattern of performance that
is indicative of poor visuo-perceptual acuity and poor
YLVXRPRWRUFRRUGLQDWLRQ+HKDVDVSHFL¿FOHDUQLQJ
disability in the areas of reading and spelling.
$WWHQWLRQDO QHHGV PDNH LW GLI¿FXOW IRU KLP WR IXOO\
access the support received.
Recommendations:
________ requires a structured programme
WR DGGUHVV KLV VSHFL¿F GLVDELOLW\ +H QHHGV LQ FODVV
support as well as one to one instruction. A further
evaluation of his attentional needs is recommended.
6SHFL¿F VXJJHVWLRQV WRZDUGV LPSURYLQJ KLV
visual acuity and co-ordination will be made (see
report).
Background:
___had been previously assessed for learning
GLI¿FXOWLHV LQ October, 2000. His parents made a
request for a current assessment, as they wanted to
take ______ for summer help in a learning centre.
Support Received:
_____ has been part of a learning support group
for Literacy and Maths. In addition, he has received
individual support 4 times a week for basic skills in
Literacy, ‘catch up’ in Math, Science, Social Studies
and for training in visual-perception.
Behaviour during Assessment:
_____ was co-operative, but was impatient
for the tests to be completed quickly. He would keep
DVNLQJLILWZDVWKHODVWµRQH¶+H¿GJHWHGZLWKWHVW
material on the desk, used the stopwatch to measure
different activities (e.g. how long I took to arrange
His mental speed for routine information
processing is good.
His ability to perceive small details, visual
sequencing, visuo-motor co-ordination and pencil
control are relatively weak.
78
WKHQH[WWHVW+LV¿UVWUHDFWLRQWRPDQ\RIWKHWHVWV
that appeared more complex (e.g. with a component
of visual analysis or writing) was – ‘Oh no! That’s
GLI¿FXOW¶±JRLQJRQWRSHUIRUPTXLWHFRPSHWHQWO\RQ
some of them.
 Annie John / Practice guidelines : Learning Disability
Intellectual Ability: The kind of reading errors that ____ made
_____’s scores on the WISC – III (UK) show were: substitution of vowel sounds, consonants,
that he has a high Verbal IQ of 120, which means words; addition of consonants and omission of part
that he would beat 91% of children of his age at this of words.
test. His Performance IQ is 101, which places him The kind of spelling errors that ______ made
at the 53rd percentile. This discrepancy between his were: GLI¿FXOWLHV ZLWK KRPRSKRQHV SKRQLFDOO\
9HUEDO DQG 3HUIRUPDQFH ,4¶V LV VLJQL¿FDQW DQG KLV attempting unfamiliar words, a confusion with
Full Scale IQ of 112 does not give a full picture of long vowel sounds and omission of vowels and
his intellectual ability. consonants. +H DOVR VKRZHG D GLI¿FXOW\ ZLWK
Cognitive Style: V\OODEL¿FDWLRQRIZRUGV
______ has acquired an adequate verbal _______ was require to write based on three
knowledge base that supports the development of oral
pictures that make a story. He was asked to take 5
and/or written language skills. Language or verbally-
minutes to plan the story, but chose to start write. He
mediated thinking and information processing is
has used a few details from the pictures, but has left
his strength. He has also shown the ability to use
out a large number of cues that could have added to
verbal contextual cues, which may lead to a good
the content. There is no evidence of the use of proper
understanding of word meanings.
nouns, adjectives or adverbs, similes or metaphors to
His retention of general knowledge facts enrich the language. In a total of 59 words, he has
and abstract verbal reasoning skills along with his used 2 seven-letter words. He has not broken up the
common sense problem solving is above average. writing into sentences and has not used paragraphs.
Although his knowledge of word meanings is good, His handwriting is large, irregular and is mostly in
his ability to express his knowledge is restricted. He print. There is enough space between most of the
RIWHQGRHVQ¶W¿QGWKHULJKWZRUGRQKLVRZQ ZRUGV7KHµU¶µQ¶DQGLXDUHOHWWHUVWKDWDUHGLI¿FXOW
His processing speed is his other strength (87th to distinguish from each other. He gets a percentile
percentile) and this indicates a good mental speed for score of 5 for writing skills.
routine information processing.
______’s attainment in Arithmetic is a Grade 6
His ability to perceive small details is his level. This is age appropriate.
weakness, and this is manifested in his reading
DQG VSHOOLQJ +H DOVR KDV GLI¿FXOW\ EUHDNLQJ GRZQ On the Brown ADD, ______ has a moderately
material into its parts. His visual perceptual and high score for inattention and impulsivity. This along
YLVXDOPRWRUVNLOOVDUHVLJQL¿FDQWO\ZHDNHUWKDQKLV ZLWK WKH IDFW WKDW WKHUH LV D VLJQL¿FDQW GLIIHUHQFH
verbal skills. between Freedom from Distractibility Index and the
His scores for the subtests forming the Verbal Comprehension Index indicates a possibility
Freedom from Distractibility Index are lower, and of a diagnosis of ADD.
VLJQL¿FDQWO\ ORZHU ZKHQ FRPSDUHG ZLWK WKH9HUEDO Conclusions:
Comprehension Index. This difference is indicative
of an attention disorder. BBBBB¶VGLI¿FXOWLHVLQWKHFODVVURRPVWHPIURP
KLVVSHFL¿FOHDUQLQJGLVDELOLW\LQUHDGLQJVSHOOLQJDQG
Diagnostic Tests: writing as well as his attentional needs. He has made
______ has a Full Scale IQ of 112 and is of improvements in reading and spelling. He continues
KLJKDYHUDJHLQWHOOLJHQFHZLWKDVLJQL¿FDQWGLIIHUHQFH WRKDYHYLVXDOPRWRUGLI¿FXOWLHV+LVPDWKVVNLOOVDUH
between his verbal and performance abilities. age and grade appropriate.
His Basic Reading Age is 7.9 years,
his Spelling Age is 8.6 years and his Reading Recommendations:
Comprehension Age is 7.3 years (WORD). These Activities that include unscrambling words
scores indicate that ___’s reading, and reading to form a coherent sentence, comic strip frames to
comprehension skills are about two years below age tell a joke, or unscrambling paragraphs to form a
expected levels. However, his comprehension could story should help _____ with developing the skill of
be affected by his poor reading skills. His spelling visualizing a whole from the parts.
age is one year below age level. Memory games and mnemonic devices should

79
 Annie John / Practice guidelines : Learning Disability
KHOSKLPUHPHPEHUVSHFL¿FWHUPVLQWKHVFLHQFHVDQG 3. Phonological Processing skills – (Rosner, J)
social studies. 4. WRAT 3 – Math
To enable _____ to function in an organized 5. Diagnostic Achievement Battery – 2 (DAB-2)
manner he should work in an environment that is  %URZQ $WWHQWLRQ'H¿FLW 'LVRUGHU 6FDOHV
structured. He should learn to rely on visual aids (Brown, 2001)
like checklists and colour codes, for e.g., he should The Wechsler Intelligence Scale for Children –
pack his school bag the previous night with the aid Third Edition, UK (WISC-III, UK)
of a checklist. He should have a school assignment The (WISC-III, UK) was administered to
book where he notes down reminders and messages. measure cognitive functioning across 12 different
His class teacher and parents could initially monitor areas, which included six verbal and six performance
this on a regular basis till it becomes an established subtests. The Full Scale is calculated from ten of
behavior. these test, with two additional subtests giving extra
Since he dislikes the act of writing, the use information about memory and speed of information
of the word processor in the long run could be processing. The scale scores are standard scores
motivating and time saving. He could make a gradual relating _____’s performance to that of individuals in
start so that he is competent with it at a later stage. the same age group.
This does not imply that _____ should not continue An average I.Q. score is between 90 and 109,
to write as well. _______ should practice writing 70 to 79 are low, 80 to 89 are low average, 110 to
between lines, paying attention to the formation of 119 are high average, 120 to 129 are high while 130
his letters to make it more legible. plus is exceptionally high. The percentile rank is the
7R LPSURYH KLV ¿QH PRWRU VNLOOV BBBB LV percentage of children of the same age in the sample,
advised to spend some time each day in activities who gained a score at the same level or below that of
OLNHPDNLQJ¿JXUHVRUIRUPVZLWKSOD\GRXJKRUFOD\ the child’s score.
paper folding activities, cutting an pasting with paper, Full Scale I.Q. 112 79th %tile
sandpapering or sewing. Verbal I.Q. 112 91st %tile
_____ should continue to receive classroom Performance I.Q. 101 53rd %tile
support and one to one instruction. He needs to be Verbal Subtests An Average score would be 10,
taught the basics of writing – sentence structure, individual scores can vary from 1 to 19.
paragraphs, elaboration of a theme and the use of
Information Retention of general knowledge facts 15
vocabulary. Support in the Social Sciences, Maths and
Similarities Abstract reasoning skills 15
Integrated Science in the classroom is recommended
Arithmetic Mental calculation of problems using a 12
as well. variety of memory skills
In the classroom, all written instructions need Vocabulary ,N=H@AłJEPEKJOKBSKN@O 10
to be read out to him before he is expected to start the Comprehension social Common sense problem solving 14
task. The teacher could prearrange a signal with ____ Digit Span Immediate verbal recall 10
to get his attention back to the task at hand. He could
be given breaks in the form of allowing him to get a Performance Subtests
drink of water, or fetching a book. The teacher should Picture Completion Visual perception of small details in 8
initiate these breaks. pictures
Coding Visual memory and speed of 12
_________, M.Phil, Ph. D., C.Psychol. information processing
April, 2003 Picture Arrangement Visual sequencing of pictures to make 12
IAClinical Psychologist – PLM a story
Block Design Spatial ability shown in three- 9
Technical Appendix: dimensional construction
Tests Administered Object Assembly Spatial ability assessed by building 10
parts into wholes to form jigsaws
1. The Wechsler Intelligence Scale for Children –
Symbol Search Visual scanning at speed 14
Third Edition, UK
2. Weshsler Objective Reading Dimensions – The subtests can be regrouped to give further
WORD LQIRUPDWLRQDERXWIRXUVSHFL¿FDUHDV

80
 Annie John / Practice guidelines : Learning Disability
1. Verbal Comprehension shows the use of
language in thinking across a variety of
question and answer tests and is calculated
from the Information, Similarities, Vocabulary
and Comprehension subtests.
2. Perceptual Organization shows the ability to
use non-verbal materials in logical ways and
is calculated from the Picture Completion,
Picture Arrangement, Block Design and Object
Assembly subtests.
3. Freedom from Distractibility measures the use
of auditory memory in verbal problem solving
without losing concentration. Auditory working
memory, short-term memory and sequencing
are required to interpret mental arithmetic
problems and to solve them applying tables’
facts. This is examined together with the ability
to remember sequences of digits presented at
one second intervals on the Digit Span Test.
4. Processing Speed is calculated from the Coding
and Symbol Search subtests. It is important for
accurate copying and for a fast writing speed.
VCI 121 92nd %tile
POI 113 81st 9%tile
FDI 106 66th %tile
Qualitative Analysis:
Basic Reading:
Substitution of :
9RZHOVRXQGV±e.g., ‘rain’ for ‘ruin’
&RQVRQDQWV±e.g., ‘that’ for ‘then’; ‘unless’ for ‘useless’
:RUGV ± ‘report bills’ for ‘responsibility’,
‘ignore’ for ‘enough’; pity’ for ‘pier’
$GGLWLRQ RI FRQVRQDQWV ± ‘angry’ and then
‘again’ for ‘again’
2PLVVLRQ RI SDUW RI ZRUG ± e.g., ‘complete’ for
‘completely’
Made some effort to decode words, but gave up and
EHJDQWRJXHVVDWWKHZRUGWDNLQJDFXHIURPWKH¿UVW
letter or sound.
Spelling:
3KRQLFDOO\DWWHPSWHG8QIDPLOLDU:RUGV
‘don’ for ‘done’; ‘pitcher’ for ‘picture’; ‘riply’ for
‘reply’; ‘edishin’ for ‘edition’; ‘wissl’ for ‘whistle’
'LI¿FXOWLHVZLWKKRPRSKRQHV
‘night’ for ‘knight’
&RQIXVLRQZLWKORQJ9RZHO6RXQGV
‘conting’ for ‘counting’; ‘carless’ for ‘careless’
2PLVVLRQRI9RZHOVDQG&RQVRQDQWVGLI¿FXOW\ZLWK
PSI 117 87th %tile V\OODEL¿FDWLRQ
FDI discrepancy with VCI – 15 ‘prushed’ for ‘produced’; ‘prvew’ for ‘preview’
Wechsler Objective Reading Dimensions (WORD) : Test of Auditory Analysis Skills (TAAS):
The three WORD subtests – Basic Reading, The TAAS is a test of auditory perceptual skills
Spelling and Reading Comprehension, enables one and investigates the ability to analyse spoken words
to view the child’s progress in acquiring fundamental into phonemes (sounds) and to map out a temporal
literacy skills from three different perspectives. sequence among the sounds.
A composite literacy score provides a measure of $JHDSSURSULDWHVFRUH+DGGLI¿FXOW\ZLWKWKLV
overall performance. WHVWDQGFRQWLQXRXVO\H[SUHVVHGKRZGLI¿FXOWLWZDV
Standard Percen- Age
Score tile DAB-2
Equivalent
Basic Reading 80 9 7.9 This is a standardized individual achievement
Spelling 90 25 8.6
Reading Comprehension 80 9
test that measures various dimensions related to
7.3
WORD Composite 80 - -learning in school. ________ was assessed for word
It is possible to compare _______’s general knowledge (synonyms), grammatic completion and
ability level (WISC-III) with his level of achievement writing (based on three pictures that make a story).
LQ OLWHUDU\ VNLOOV 7KLV FDQ EH GRQH E\ ¿QGLQJ WKH A standard score of 8 -12 is within the average range
difference between actual achievement and predicted and a percentile rating of 50 is average.
value. Std score Percentile
Synonyms 9 37th %tile
Predicated Actual 0ECJEł-
Difference Grammatic Completion 8 25th %tile
WORD WORD cance
Basic Reading 107 80 -27 0.01 Writing 5 5th %tile
Spelling 106 90 -16 NS He was asked to take 5 minutes to plan the
Reading Com- story, but chose to start write away. There is no
108 80 -28 0.01
prehension
evidence of the use of proper nouns, adjectives or

81
 Annie John / Practice guidelines : Learning Disability
adverbs similes or metaphors to enrich the language. vision, which were noticed and an Optometrician
Number of words – 59 was consulted. She currently wears spectacles to
Vocabulary – limited aid in clear vision. Reading, spelling and writing
Expression – poor, GLI¿FXOWLHV EHFDPH PRUH SURPLQHQW 6KH KDV DOVR
Use of sentences – no changed two schools.
Use of paragraphs – no Currently there appears to be a marked
+DQGZULWLQJ discrepancy between her verbal abilities and her
Large, irregular print. There is enough space between ability to translate this into the written format. She
most of the words. The ‘r’/ ‘n’ and i/u are letters that also tends to forget what she reads quite fast. She does
DUHGLI¿FXOWWRGLVWLQJXLVKIURPHDFKRWKHU not have problems with maths. The problem appears
to be more prominent for languages and history/
WRAT 3 – Math social studies. The mother reported (and this was
Assesses numerical computational skills ODWHUFRQ¿UPHGE\;;;;WKDWVKHGLGQRWDWWHPSW
Standard Score 119 Grade level 6 long answers as she would forget part of the answer.
If that happened then she would lose the trend of her
Brown ADD Scales:This tool integrates information thought and could not continue further. The mother
from a variety of sources for a comprehensive also reported that sometimes she is not aware of the
DVVHVVPHQWRI$WWHQWLRQ'H¿FLW+\SHUDFWLYLW\ mistakes she makes. Short answers, though correct,
Disorders and associated symptoms. tend to have plenty of spelling mistakes and as a
Inattention – 7/9 consequence she tends to get fewer marks.
Hyperactivity – 2/6 Forgetting, however, appears to be related only
Impulsivity – 3/3 to schoolwork. Her ability to socialize and make
Example -2 friends remains unaffected. She also shows a keen
interest in other activities as told by the mother. No
Neuropsychological Assessment Report attention or behavior problems were mentioned by
Name: XXXX the mother.
Gender: Age:
Date of Birth: Date(s) of testing: On observation, XXXX appeared to be a
Name of School: Class quiet and patient girl who was willing to work with
the tasks given to her. She did not ask many questions
Reason for Referral: that would interrupt the session and showed keen
 'LI¿FXOWLHVLQUHDGLQJZULWLQJDQGVSHOOLQJ interest in attending to the tasks on hand. Preliminary
2) Poor concentration observations did not reveal any signs of restlessness
3) Discrepancy between oral and written or behavior problems. She had adequate attention and
responses. was able to sustain it over the entire testing period.
4) Makes spelling mistakes and tends to get low +RZHYHUVKHZDVQRWDEOHWRYHUEDOL]HKHUGLI¿FXOWLHV
marks for answers. in the initial session. XXXX was assessed over two
History : sessions of 90 minutes each.
XXXX is a 13-year-old girl studying in class 8. Tools Used:
The mother reported that XXXX was a very friendly 1. Standard Progressive Matrices (SPM)
girl with many friends and an ability to get al.,ong
2. Digit Span (subtest of WISC III)
well with people. She liked being with people and
was known to be good with children. The primary 3. Letter-number Sequencing (subtest of WAIS
problem for which the mother sought help was her III R)
academic performance. Since XXXX joined school 4. Stroop Colour Word test
(LKG in Madurai), the teachers and the mother 5. Bender Gestalt test
noticed problem behaviours. She was found to be 6. Rey Ostriech Complex Figure Test (RCFT)
restless in class and would frequently ask the teacher 7. Phonological Awareness test (Gillion and
to let her go out and play. As she went from one class Dodds, 1999 version)
to another the mother noticed that she struggled to 8. Reading subtests (NIMHANS SLD Battery)
keep up with the class. She had problems in her 9. Corsi Block Taping test

82
 Annie John / Practice guidelines : Learning Disability
10. Block Design (subtest of WISC) 6SHFL¿F/HDUQLQJ'LI¿FXOWLHV
 )$63KRQHPLFÀXHQF\ 5HDGLQJ
12. Category Fluency Test (subtest of NIMHANS The NIMHANS SLD battery was used to
Neuropsychological battery) H[SORUH IRU GH¿FLWV LQ UHDGLQJ7KH VXEWHVW FRQVLVWV
13. AVLT (subtest of NIMHANS Neuropsycho- of standardized reading passages, which she would
logical battery for children) be required to read aloud. After which she would
Rationale for choosing the tests: be asked a few questions to assess her ability to
The above-mentioned tests were chosen for the comprehend what she has just read. XXXX read
following reasons: the passages with adequate speed and showed
1. Intelligence to estimate current levels of good intonations while reading. Punctuations
functioning (SPM) were attended to while reading. However, she had
2. SLD subtests and Phonological awareness to GLI¿FXOWLHV UHDGLQJ XQIDPLOLDU ZRUGV (UURUV VXFK
explore for current levels of reading, writing, as guessing at words (e.g. read the word as monkey
spelling and phonological awareness. instead of money), omission (e.g. ‘the’ and word
3. Neuropsychological tests to explore for endings were omitted while reading) and additions
SRVVLEOH 1HXURSV\FKRORJLFDO GH¿FLWV QRW (e.g. fruits for fruit) were evident. She also displayed
evident in routine testing. poor word attack skills i.e. she could not draw upon
cues or strategies to read new/unfamiliar words. She
7KHDLPZDVWRREWDLQDFRPSOHWHSUR¿OHRIWKH
was reading 3 years below her current expected level.
child on the various parameters, which would help in
Comprehension was intact suggesting the XXXX
providing a complete understanding of her strengths
was able to understand what she was reading despite
DQG ZHDNQHVVHV ,Q DGGLWLRQ WKH SUR¿OH ZRXOG DLG
KDYLQJGLI¿FXOWLHVZKLOHUHDGLQJ
in providing a solid framework for rehabilitation to
be planned after the assessment. SPM was the test 6SHOOLQJ
of choice for intellectual assessment as it was a non- Spelling was assessed using the spelling words
verbal test of. Reading, writing (obtained from a from the Phonological awareness list. Spelling errors
free writing passage) and spelling were assessed to were present. Some words were spelt phonetically
H[SORUHIRUVSHFL¿FGH¿FLWVLQWKHVHDUHDV,QDGGLWLRQ (e.g. “cacher” for catcher, “jat” for jet). Most errors
the phonological awareness tests would throw light on were found with irregular words. This is suggestive
her phonological abilities. The Neuropsychological RIGLI¿FXOWLHVLQVSHOOLQJDQGRUJDQL]LQJWKRXJKWDQG
assessment included attention, executive functions, converting thoughts into words.
verbal learning and memory, visual integration and :ULWLQJ
organization, visual construction abilities and visual
and memory abilities. Writing was assessed on the basis of a writing
sample. She was asked to write about anything she
Findings on the tests: likes and she chose to write about her pet. She wrote
The entire assessment was carried out across only 3 lines and refused to write anything more than
WZRVHVVLRQV7KH¿QGLQJVRIWKHWHVWVDUHGLVFXVVHG this. The sentence structure was simple and short.
under separate headings for SLD, Intelligence and Words were factual rather than descriptive. The
1HXURSV\FKRORJLFDOSUR¿OHV ZULWLQJVDPSOHLVVXJJHVWLYHRIGLI¿FXOWLHVLQVSHOOLQJ
Intellectual Functioning: and organizing thought and converting thoughts into
XXXX was assessed on the SPM a non-verbal words.
test of intelligence. SPM is a non-verbal test where 3KRQRORJLFDO$ZDUHQHVV(Sthal and Murray, 1994):
a piece of a picture is missing. Below the picture are This consists of lists of words divided into
6-8 choices of which only one completes the picture. sections. Each section consists of 5-15 words and the
Drawing from logic and her ability to reason, she instruction given before each section primes the child
has to choose the correct option. There are 60 such on what needs to be done. Phoneme blending requires
problems revealed that she has average intelligence. one to identify the word that is made by putting a
Some intra-test scatter is seen suggesting that few sounds together. E.g. /m/ /a/ / p/ spells ‘map’.
HPRWLRQDO DVSHFWV PLJKW KDYH LQÀXHQFHG KHU 3KRQHPH LVRODWLRQ UHTXLUHV RQH WR VD\ WKH ¿UVWODVW
performance. Since it is a non-verbal test it would be sound of each word read out. Segmentation refers to
DWUXHUHÀHFWLRQRIKHUDELOLWLHVGHVSLWHKHUUHSRUWHG the ability to break down a word into its sounds (e.g.
DFDGHPLFGLI¿FXOWLHV VKHHSZRXOGEHEURNHQLQWRVKHHSDQG¿QDOO\

83
 Annie John / Practice guidelines : Learning Disability
phoneme deletion refers to the ability to say a word of wood (and round objects), as she could, in one
ZLWKRXWDSDUWLFXODUVRXQGHJ³VD\ÀDWZLWKRXWWKH, PLQXWH6KHKDGGLI¿FXOW\JHQHUDWLQJZRUGVXQGHUWKH
sound”. XXXX was assessed on phonemic blending, SKRQHPLFÀXHQF\ZRUGVRQDYHUDJHVXEWHVWVZKLOH
phoneme isolation, phoneme segmentation and
phoneme discrimination. Accuracy in performance
ZDVORZDFURVVDOOWKHWDVNVWKHPRVWGLI¿FXOWEHLQJ
Phoneme segmentation.
Summary:
The SLD assessment is suggestive of
GLI¿FXOWLHV LQ UHDGLQJ ZULWLQJ VSHOOLQJ DQG
phonological awareness.
Neuropsychological Assessment:
This consisted of a number of individual
tests. The results will be reported on the basis of the
functions that the tests represent.
$WWHQWLRQ was assessed on digit span (forward) subtest
of WISC III R. Digit span forward requires the child
to listen to a list of numbers read in increasing order
(i.e. 2 digit numbers to 8 digit numbers) and repeat it.
On digit forward her span was 5 digits (with a score
IRUFDWHJRU\ÀXHQF\ZRUGVRQDYHUDJHVKHGLGQRW
VKRZPXFKGLI¿FXOW\7KLVLVVXJJHVWLYHRIGLI¿FXOWLHV
in searching for words using phonemic cues.
Interference control was assessed on the Stroop
colour word test. The test consists of a list of names of
colours written in coloured ink (e.g. the word “blue”
is written in red ink). The child is asked to name
the colour of ink in which the word is written (in
the above example she would have to say red). The
child is asked to read as many words as possible in 45
seconds. It tests her ability to handle interference. In
the presence of a well-learnt response (e.g. reading
the word) she is asked to give a new response (i.e.
name the colour of ink). Scores are suggestive of
her ability to inhibit a well-learned response in the
presence of more appropriate responses. XXXX’s
UHVSRQVHVRQWKLVWHVWDUHVXJJHVWLYHRIGLI¿FXOWLHVLQ
the ability to inhibit a well-learnt (but irrelevant in the
of 8) suggesting adequate attention span.
([HFXWLYH IXQFWLRQV consists of working memory,
VHW VKLIWLQJ SODQQLQJ ÀXHQF\ DQG LQKLELWLRQ
interference control.
:RUNLQJ 0HPRU\ (WM, refers to the ability to
manipulate information while holding onto other
information) was assessed on digit backward (verbal
WM) and Corsi block tapping forward and backward
tests (visuo-spatial WM). Digit span backwards
refers to a list of 2 digit-8digit numbers read one
after another in increasing order and the child has
to repeat the numbers in reverse. On the Corsi test
she is required to tap a set of blocks (arranged in
a predetermined order) just as it is shown by the
examiner (forward) or to reverse it (backward).
Assessment reveals that XXXX had adequate visuo-
FXUUHQWFRQWH[WUHVSRQVHLQGLFDWLYHRIGLI¿FXOWLHVLQ
executive functions.
9HUEDO 0HPRU\ was assessed using the auditory
verbal learning test. This test consists of two lists of
ZRUGVHDFK2QHOLVWLVSUHVHQWHG¿YHWLPHVDQG
she is asked to recall the words, assessing the ability
to acquire information across trials. The second
list is presented once and is used to assess the role
of interference in learning. In addition, subsequent
recall trails of list one assess delayed recall i.e. the
child’s ability to retain information over a period of
time. Her performance shows that the amount she is
able to learn in the initial trials is low. After the 5th
trail she was able to learn 10 out of the 15 words.
However in the subsequent trials she could remember
all the 10 words learnt suggesting that the effect of
VSDWLDOEDFNZDUGWULDOV+RZHYHUVKHKDGGLI¿FXOW\
on the digit backward test with a span of 3 suggesting
GLI¿FXOWLHVLQYHUEDOZRUNLQJPHPRU\7KLVZDVDOVR
evident on other tests in the form of perseverations.
On the letter number sequence test a list of letters
and numbers are read and each time the child has
to arrange the letters in alphabetical order and the
numbers in ascending order. Her performance (score
interference is minimal and forgetting is not present.
7KH ORZ QXPEHU RI ZRUGV UHFDOOHG LQ WKH ¿UVW 
WULDOVVXJJHVWVWKDWVKHKDVGLI¿FXOW\LQDFTXLVLWLRQ
XSWDNHRILQIRUPDWLRQ+RZHYHUVKHKDVQRGLI¿FXOW\
recalling what ever is acquired across trials.
9LVXDO6SDWLDO/HDUQLQJDQG0HPRU\was assessed
XVLQJ5&)7$FRPSOH[¿JXUHLVSODFHGEHIRUHKHU
DQG VKH LV DVNHG WR FRS\ WKH ¿JXUH 7KLV DVVHVVHV
RIRQWKLVWHVWLVDOVRVXJJHVWLYHRIGLI¿FXOWLHVLQ
working memory especially in the verbal domain.
3KRQHPLF)OXHQF\DQG&DWHJRU\)OXHQF\XXXX
was asked to generate as many words as she could
in one minute, starting from a particular letter. Three
her visual perceptual ability. Immediately copying
VKHZDVDVNHGWRGUDZWKH¿JXUHIURPPHPRU\7KLV
assessed her immediate memory for visual objects.
After 5 minutes and after 20 minutes she was asked to
GUDZWKHVDPH¿JXUHIURPPHPRU\5HVXOWVVXJJHVW
VXFKWUDLOVZHUHJLYHQSKRQHPLFÀXHQF\,QFDWHJRU\ she has adequate visual-spatial abilities. This was also
ÀXHQF\VKHZDVDVNHGWRQDPHDVPDQ\REMHFWVPDGH observed on the BGT (where she was able to copy 8

84
 Annie John / Practice guidelines : Learning Disability
JHRPHWULF ¿JXUHV ZLWKRXW DQ\ GLI¿FXOW\ +RZHYHU Assessed by:
VKH KDG GLI¿FXOWLHV LQ SODQQLQJ WKH GUDZLQJV DQG
Appendix B
had to frequently erase and redraw them. While
Remediation:
attempting to recall the CFT, however she was unable
Although remediation in terms of teaching
to recall some facts across all the memory trails. This
skills to the child with SLD is mostly carried out
is suggestive of mild forgetting of visual information
by the special educator, it is important for the
QRWDPRXQWLQJWRDGH¿FLW Clinical Psychologist to be aware of research based
Visual integration and visual construction techniques.
abilities were assessed on the block design test. In
this test she was given 4 blocks and asked to form Reading and Spelling:
a design with the blocks by looking at a pictures Intervention at an early phase would emphasize
placed in front of her. The pictures required 4 blocks phonemic awareness and phonic knowledge. Most
initially to construct the picture and later required 9 special educators are familiar with programmes and
blocks to complete the task. On the block design test techniques that stem out of the Orton – Gillingham
performance revealed that she had adequate visual approach. The child is taught the phonemic
integration and had adequate planning and ability to sounds of the letters and their combinations and
learn from experience. then to blend these sounds to form a word using a
multisensory approach. The following websites carry
1HXURSV\FKRORJLFDO,PSUHVVLRQ more information and references on the different
The Neuropsychological assessment is suggestive of programmes. http://www.Idonline.org/article/
GH¿FLWVLQH[HFXWLYHIXQFWLRQVLQWKHIRUPRIYHUEDO Components_of_Effective _Reading_Instruction
ZRUNLQJPHPRU\SKRQHPLFÀXHQF\SRRUSODQQLQJ
and poor interference control. Writing:
Remedial teaching in writing comprises
Summary of Complete Assessment: strategies to be taught during the 3 stages of writing:
XXXX is a 13-year-old girl referred for planning before writing, the actual writing process
DVVHVVPHQW IRU GLI¿FXOWLHV LQ UHDGLQJ ZULWLQJ DQG and proof reading after writing.
spelling. A complete assessment was conducted to
Arithmetic Skills:
explore her current level of functioning and to explore
The arithmetic skills intervention process
SRVVLEOHGLI¿FXOWLHVLQDQXPEHURIDUHDV$VVHVVPHQW
generally proceeds in a bottom up manner, starting
UHYHDOV WKDW ;;;; KDG GLI¿FXOWLHV LQ VSHFL¿F
with basic facts of number comprehension and
DUHDV ZKLFK FDQ KHOS WR H[SODLQ WKH GLI¿FXOWLHV production viz. larger than, smaller than comparison,
VKH LV H[SHULHQFLQJ LQ KHU DFDGHPLFV 7KH GH¿FLWV odd-even segregation of numbers, sequence
LQFOXGHGLI¿FXOWLHVLQUHDGLQJZULWLQJDQGVSHOOLQJ completion, reading of large numbers, writing of
VXJJHVWLYHRIVSHFL¿FOHDUQLQJGLI¿FXOWLHVLQDOOWKUHH larger number, use of place values, arranging in
DUHDV SRRU SKRQRORJLFDO DZDUHQHVV DQG GH¿FLWV LQ ascending/descending orders, etc. On ensuring the
YHUEDOZRUNLQJPHPRU\ÀXHQF\LQWHUIHUHQFHFRQWURO FKLOG¶VSUR¿FLHQF\LQWKHVHPRGXOHVWKHQH[WOHYHORI
and visual integration. Visual learning and memory number processing is initiated. Remediation targets
LVLQWDFWFDWHJRU\ÀXHQF\DQGYLVXDOVSDWLDOZRUNLQJ WKHOHYHORIGLI¿FXOW\WKDWWKHFKLOGLVH[SHULHQFLQJ
PHPRU\GRHVQRWVKRZDQ\GH¿FLWV,QWHOOLJHQFHLVLQ
the average range. A general format to follow in introducing
arithmetic skills would be to introduce the concept
Recommendations: and proceeding from concrete to symbolic and then
%DVHGRQWKHSUR¿OHRIGH¿FLWVWKHIROORZLQJ to abstract. The abstract stage is when the child is
recommendations are made: asked to use only the numbers written and work out
 ;;;; ZRXOG EHQH¿W IURP UHJXODU LQSXWV WR the problem without resorting to concrete objects or
improve her academic skills. symbols.
2. Cognitive rehabilitation to improve working Learning Strategies:
memory and other executive functions. Listed below are some learning strategies that can be
 6SHFL¿F LQSXWV WR LPSURYH SKRQRORJLFDO used with the older student.
awareness and enhance her spelling. The SQ3R Method :
4. Regular remedial training with some training SQ3R stands for Survey, Question, Read, Recite and
on study skills may be required at a later stage. Review.

85
 Annie John / Practice guidelines : Learning Disability
Survey – Get the best overall picture of what one is
going to study BEFORE studying it any detail. It’s
like looking at a road map before going on a trip.
Question – Ask questions for that will aid learning.
The important things to learn are usually answers
to questions. Questions should lead to emphasis on
the what, why, how, when, who and where of study
content.
Read – Reading is NOT running one’s eyes over
a textbook. Active reading should be emphasized.
Reading to answer questions, being alert to words in
italics and bold print are useful tips as these are present
in the text to indicate a certain degree of importance.
Also, ensure that the child reads everything –
including tables, graphs and illustrations. Often
tables, graphs and illustrations can convey an idea
more powerfully than written text.
Recite – The child has to be encouraged to
periodically stop reading and recall what is being
read. Recall of main headings, important ideas of
concepts presented in bold or italicized type, and
what graphs charts or illustrations indicate should be
done periodically. Developing an overall concept and
attempting to connect things already known to things
just read are useful strategies that aid in better recall.
Review – A review is a survey of what is covered. It
is a review of what one is supposed to accomplish,
not what is to be done. Rereading is an important
part of the review process. Rereading with the idea
that one is measuring what has been gained from the
process is essential. During review, it is good to go
over notes taken to help clarify points missed. The
EHVW WLPH WR UHYLHZ LV ZKHQ \RX KDYH MXVW ¿QLVKHG
studying something.
(IIHFWLYH QRWH WDNLQJ XVH RI ÀDVK FDUGV
using the peg word system and mnemonics and
visualization are additional strategies that are useful
in enhancing memory.
The most common mnemonic, the FIRST x
Mnemonics :
VWUDWHJ\LQYROYHVXVLQJWKH¿UVWOHWWHURIHDFKZRUG
in a list to spell out one cue word. This method is
easiest to use when the items in the list can be
scrambled around in order to form simple cue words
or sentences. Associating cue words with a visual x
image also aids in recall.
x
x
Form a cue word.
Use the beginning letters of words in the list to 5. Organizational Skills :
x
make a word that is easy to remember.
Use capital letters for all letters of the cue word through exam times is often the biggest challenge for
86
x
that are found in the list.
x
Insert a letter
Insert a new letter if the existing letters alone
x
don’t make a word.
Use a lower case letter for the insertion so it
x
will be clear that it doesn’t mean anything.
x
Shape a cue sentence or phrase.
If no cue word can be made, use the beginning
letters of the words to make a sentence or phrase.
Cornell method of note taking:
This note taking format provides the perfect
opportunity for following with the 5 R’s of note-taking.
Record:
While the teaching is going on the student
should record as many meaningful facts and ideas as
possible in the main column.
Reduce:
As soon as possible, after these facts and ideas
should be summarized concisely in a Cue Column.
6XPPDUL]LQJ FODUL¿HV PHDQLQJV DQG UHODWLRQVKLSV
reinforces continuity, and strengthens memory.
Recite:
Next the student should cover the Note Taking
Area, and using only jottings in the Cue Column, repeat
the facts and ideas of what was taught in as detailed a
manner as possible. Then, verify what has been said.
5HÀHFW
Draw out opinions from the notes and use them
DVDVWDUWLQJSRLQWIRUUHÀHFWLRQVRQWKHWHDFKLQJDQG
KRZ LW UHODWHV WR WKH VXEMHFW 5HÀHFWLRQ ZLOO KHOS
prevent ideas from being inert and soon forgotten.
Review:
The student should review the notes before the
next lesson.
4. Strategies for multiple choice questions:
Multiple-choice answers usually include a
correct answer, an answer that is obviously wrong,
and two answers that are close to the correct one.
Read the question while covering up the
DQVZHU FKRLFHV $QVZHU WKH TXHVWLRQ ¿UVW
in your head (or work it out in paper), then
¿QG WKH JLYHQ DQVZHU WKDW EHVW PDWFKHV \RXU
original response.
You can cross out the choice that is wrong and
use a process of elimination to help limit the
number of answer choices.
The process of helping a child and a parent
 Annie John / Practice guidelines : Learning Disability
professionals working with older children with SLD.
Apart from learning strategies – some of which have
been outlined above, it is important to make sure
that the child follow some general practices that will
allow learning to take place.
Getting organized to study allows the child to
focus attention on the task at hand. An inability to
sustain attention, and easy distractibility are common
complaints of children when they study. Effective
x
methods of enhancing concentration are:
Identify and maintain a special place and time
&UDZIRUG6*6SHFL¿FOHDUQLQJGLVDELOLWLHVDQGDWWHQWLRQGH¿FLW
hyperactivity disorder: Under-recognized in India. Indian Journal of
Medical Science. 61, 637-638.
Demb, J.B., Boynton, G.M., & Heeger, D.J. (1997). Brain activity in
visual cortex predicts individual differences in reading performance.
Proceedings from the National Academy of Science. 94, 133 -163.
Duara, R., Kushch, A., Gross-Glenn, & K., Barker et al. (1991). Neuropsy-
chological differences between dyslexic and normal readers on mag-
netic resonance imaging scans. Archives of Neurology. 48, 410-416.
Ellenbogen, J. M., Hulber, J. C., Stickgold, R, Dinges, D. F & Thompson-
Schill, S. L. (2006). Interfering with Theories of Sleep and Memory:
Sleep, Declarative Memory, and Associative Interference. Current
Biology. 16, 13, 1290-1294.
x
to study.
Ensure people around – the family are aware
x
that the child is studying.
$GYLFH WKH FKLOG WKDW LI WKH\ ¿QG WKHLU PLQG
wandering on unnecessary things they should
set aside a different time of the day to think
x
about those aspects.
x
Adequate breaks should be taken.
The child should alternate between easy and
GLI¿FXOWWRSLFVWRHQVXUHDGHTXDWHDWWHQWLRQ
Research shows that so-called declarative
PHPRULHV±VXFKDVDVHTXHQFHRIIDFWV±DOVREHQH¿W
from sleep, especially when students are challenged
with subsequent, competing information (Ellenbogen,
Hulber, Stickgold, Dinges & Thompson-Schill,
2006). Students with SLD usually spend many hours
learning and tend to deprive themselves of sleep.
These are simple yet handy tips for the parent as
well as children to help them organize their time better.
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ZLWKVSHFL¿FOHDUQLQJGLVDELOLW\DQGFRRFFXUULQJDWWHQWLRQGH¿FLWK\-
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Indian Journal of Clinical Psychology
2013, Vol. 40, No. 1, 90.
BOOK REVIEW
E D M R Therapy and Adjunct Approaches with Children:
Complex Trauma, Attachment, and Dissociation
Edited by: Ana M Gomez, M C, LPC
Publisher’s Name and Address: Springer Publishing Company, New York
Published in 2013
Pages: 344
Price: $ 55
Eye Movement Desensitization and Reprocessing
(EMDR) therapy is now validated and independently
designated as an evidence-based psychotherapeutic
approach. Results of recent meta-analyses show
(0'5 DV DQ HIIHFWLYH DQG HI¿FDFLRXV WUHDWPHQW
for Posttraumatic Stress Disorder (PTSD) in adults
and children. The book entitled ³(0'57KHUDS\
DQG$GMXQFW$SSURDFKHVZLWK&KLOGUHQ&RPSOH[
7UDXPD $WWDFKPHQW DQG 'LVVRFLDWLRQ´ by Anna
Gomez meticulously provides developmentally
appropriate strategies and protocols to assist in
treating children with complex trauma, including
dissociative symptoms, attachment issues and
inappropriate behaviours.
The relational aspect is a key ingredient
when providing treatment to children and families,
however, sometimes it can be extremely challenging
to create and sustain a therapeutically positive and
trusting relationship with traumatized children.
The book has aptly given valuable resources to
address these important issues. Gomez has applied
foundational theories of brain physiology to support
the comprehensive treatment protocols which she
developed to prepare the avoidant, dysrequlated child
and to provide caregivers opportunities to positively
and empathetically interact with their children.
The book provides creative, step-by-step,
“how to” information about the EMDR therapy
and methodically takes the reader through the
standard EMDR protocol inclusive of all eight
phases, engaging the child’s participation in each
phases through various playful activities and
creative, often, nonverbal exercises. Further, joyful,
concrete, “hands-on”, activities are appropriately
included so as to help engaging even the most
oppositional child and naïve parent. The author
has been mindful of and sensitive to the socio-
cultural background, religious beliefs, and values
89
Copyright, 2013 Indian Association of
Clinical Psychologists (ISSN 0303-2582)
of her clients. Further, the author adheres to the
adaptive information processing (AIP) model as
the theoretical basis for case conceptualization and
treatment planning with children and she judiciously
introduces the concept of AIP and basics of EMDR
steps to children through concrete language and
innovative, nonthreatening activities that appeal
to their imagination, cognitive ability, and right-
brain function while simultaneously building and
maintaining a trusting therapeutic relationship.
Throughout the book, employing playfulness and
creating safety are underlining elements utilized to
help children understand and become involved in the
process of healing. The author ingeniously illustrates
how she builds rapport and engages family members
in the therapeutic process through poignant case
examples; in addition she gives beautiful description
about how she integrates music, art, sand tray, and
play therapies with EMDR as well as other adjunct
therapeutic approaches. Importantly, she has tried to
integrate elements and strategies of internal family
systems (IFS) psychotherapy into eye movement
desensitization and reprocessing (EMDR) therapy
with complexly traumatized children.
The book highlights our understanding of
how our biological apparatus is orchestrated, how
its appropriate development is derailed when early,
chronic and or pervasive trauma and adversities
KDYHEHHQVLJQL¿FDQWO\SUHVHQWLQRXUOLYHVDQGKRZ
healing can be promoted through the application
of EMDR therapy. Besides, it provides a practical
guidelines to help caregivers develop psychological
attunement and synchrony as well as to enhance and
improve their mentalizing capacities, resulting in
meaningful integration in therapeutic process.
Amool R. Singh
Prof. & Head , Dept. of Clinical Psychology and
Director, RINPAS, Kanke, Ranchi (Jharkhand)
BB$QQDSXUQD3UHVV‡